00196B01.001

INTEGRATED PLANNING ACT 1997                                                                                                 Part A, Version 3.1, 3 March 2008
Table 0    Complete if the premises are adjacent to or associated with a water body, watercourse or aquifer (e.g. river, creek, fake, canal)
                                                            Name of water body, watercourse or aquifer (if known)
             a
Table E    Complete if the premises are on Strategic Port Land under the Transport infrastructure Act 1994
                              Lot on plan description for strategic port land                                 Port Authority for the lot                    |
               as
Table F    Complete if the premises are in tidal water
                         Name of local government for the tidal area (if appicable)             Name of port authority for the tidal area (If appicable)

3.     Indicate the total area of the premises on which the development is proposed: (Note: The total area may include land both above and below water)
                              Total area of premises                      -
     47,30                [X] m? [_] hectares       (Tick applicable unit)

 Existing use of the premises
—
4,     Current use/s of the premises: (e.g. vacant land, house, fownhouses, apartment building, shop, service station, school, sugar cane farming etc.)
                   Shops, restaurant and unit
 5.    Are there any existing easements on the premises? (e.g. for vehicular access, electricity, overland flow, water etc.)?
     L] No         x Yes - Ensure the type, location and dimensions of each easement are included in plans, submitted with the application
‘Proposal details                                                                                                                                            ]
el
 6.    Brief description of the proposal (e.g. 6 unit apartment building, 30 Jot residential subdivision, a bore, aquaculture)

 Coffee shop and outdoor seating

 7.    Does the poposal include new buildings or operational work (including any services) on the premises?
       [IX] No     [_] Yes - Ensure the nature, location-and dimensions of the proposed works are included in plans, submitted with the application
‘Resource entitlement {if applicable) - further information is provided in the advice section at the end of the form
 8.   Does the application involve taking or interfering with a State resource and therefore require a resource entitlement? (e.g. the appiication
      involves State land {leased and freehold), dectared Fish Habitat areas, taking quarry material, taking or interfering with water under the Water Act 2000, etc.)
       &X   No - Goto Q9       C] Yes - Complete Table G - provide details for each evidence required on a separate row, if applicable. Evidence of resource
                                            allocation or entitlement must be submitted with the application. You do not need to answer Q9 - go to the next section.
 ‘Owner's consent (if applicable} - further information is provided in the advice section at the end of the form                                             ]
 9.   Complete Table H for applications involving a material change of use; reconfiguration of a lot; work on land below high-water mark and
      not within a canal as defined under the Coastal Protection and Management Act 1995; or work on rail corridor land defined under the
      Transport Infrastructure Act 1994 - provide details for each owner on a separate row, or on an attachment to this form if applicable.
                           Premises Owner's name/s                 Details of the premises owned                           .       *        Date consent |
 Table H                       and postal address               (street address or fot on plan description)     Owner's signature           was obtained

  * Owners signature cannot be provided on the form if you intend to submit the application electronically. Owner's consent must be provided to the assessment manager on an
   attachment containing appropriate written documentation of the owner's consent. If the owner is a company, $127 of the Corporations Act 2001 (Cwealth) details how a
   company may sign as owner. Templates for the provision of owner's consent are available on the IPA website .
  Attachments and supporting information (Complete Table | - Use a separate row for each type of attachment or information, including information required
 lunder this Part} Please ensure all documentation submitted with this form, including other Parts of Form 1, or owner's consent, etc, are securely attached to this Part of the Form.
  rable                   a etn fatter iors                                  cn         tl apts                                        Meta of      ey |
                               ‘art C of Form 1, owner's 4   nce
                            O  Sloctcnlanttoras mt, plans, drawings, reposts) (2.9. General Authority, James StreetTraffic Report)     assessment manager .

                apo