200394 - 161 Cooroy Belli Creek Road, COOROY - DA Form 2 - Building work details - Planning Act 2016 - 7 February 2020

 All information relating to this development application may be available for inspection and purchase, and/or
 published on the assessment manager’s and/or referral agency’s website.
 Personal information will not be disclosed for a purpose unrelated to the Planning Act 2016, Planning Regulation
 2017 and the DA Rules except where:
  such disclosure is in accordance with the provisions about public access to documents contained in the Planning
      Act 2016 and the Planning Regulation 2017, and the access rules made under the Planning Act 2016 and
      Planning Regulation 2017; or
  required by other legislation (including the Right to Information Act 2009); or
  otherwise required by law.
 This information may be stored in relevant databases. The information collected will be retained as required by the
 Public Records Act 2002.


PART 7 – FOR COMPLETION BY THE ASSESSMENT MANAGER – FOR OFFICE
USE ONLY

 Date received:      22/01/2021                Reference numbers:    200394

For completion by the building certifier
Classification(s) of approved building work
1a, 10a
Name                                     QBCC Certification Licence number                  QBCC Insurance receipt
                                                                                            number
Luke Owen-Jones                               A1035338                                      014169007

 Notification of engagement of alternative assessment manager
 Prescribed assessment manager                               Luke Owen-Jones
 Name of chosen assessment manager                           Luke Owen-Jones
 Date chosen assessment manager engaged                      22/01/2021
 Contact number of chosen assessment manager                 07 3063 9391
 Relevant licence number(s) of chosen assessment             A1035338
 manager


 Additional information required by the local government
 Confirm proposed construction materials:
                                        ☐ Double brick                ☐ Steel                     ☐ Curtain glass
 External walls                         ☐ Brick veneer                ☐ Timber                    ☐ Aluminium
                                        ☐ Stone/concrete              ☐ Fibre cement              ☐ Other
                                        ☐ Timber                      ☐ Steel                     ☐ Aluminium
 Frame
                                        ☐ Other
 Floor                                  ☐ Concrete                    ☐ Timber                    ☐ Other
                                        ☐ Slate/concrete              ☐ Tiles                     ☐ Fibre cement
 Roof covering
                                        ☐ Aluminium                   ☐ Steel                     ☐ Other


 QLeave notification and payment
 Note: For completion by assessment manager if applicable
 Description of the work                                    Dwelling and garage / Dwelling and garage
 QLeave project number
 Amount         $0.00                                       Date paid
 paid ($)                                                   (dd/mm/yy)

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                                                                                                DA Form 2 – Building work details
                                                                                                  Version 1.2— 7 February 2020