Img_20211001_0004

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3.2) Coordinates of premises (appropriate for development in remote areas, over part of a lot or in water not adjoining or adjacent to land

e.g. channel dredging in Moreton Bay)
Note: Place each set of coordinates in a separate row.

| LJ Coordinates of premises by longitude and latitude
Longitude(s) Latitude(s) Datum Local Government Area(s) (if applicable)

| wese4
L] GDA94

CJ Other

(oO Coordinates of premises by easting and northing

 

 

 

 

Easting(s) Northing(s) Zone Ref. | Datum Local Government Area(s) (if applicable)
54 C1 wess4
L155 CL Gpag4
L] 56 CJ Other:

3.3) Additional premises

| (J Additional premises are relevant to the original development approval and the details of these premises have
been attached in a schedule to this application
Not required

 

 

PART 3 — RESPONSIBLE ENTITY DETAILS

4) Identify the responsible entity that will be assessing this change application
Note: see section 78(3) of the Planning Act 2016

NeeSA Covrde

 

PART 4 — CHANGE DETAILS

5) Provide details of the existing development approval subject to this change application

| Approval type | Reference number | Date issued | Assessment
| | manager/approval entity

 

  

 

ae a= 2 Pom ek Dew Rn Sen 2 reso | bee re ees eg rg
| Development permit C UY b L2G > lEW oo

| (J Preliminary approval he /' Jo a/ . /17 | LaopFoRI7

| (J Development permit | PGF we = pal y f | WILITELELT —
Preliminary approval MEU /é /0/3 fh o/ = f ap ae | KOSCHADE

 

 

6) Type of change proposed

6.1) Provide a brief description of the changes proposed to the development approval (e.g. changing a development
approval for a five unit apartment building to provide for a six unit apartment building):
Retr A Stéero YO Acton cota Mischa gk

TER WAgL ec ey ie -

Minor change application — proceed to Part 5
_| Other change application — proceed to Part 6

 

Page 2
Planning Act Form 5 - Change application form
Version 1.2 — 7 February 2020

Page 3

PART 5 — MINOR CHANGE APPLICATION REQUIREMENTS

7) Are there any affected entities for this change application

| VM No — proceed to Part 7

CJ Yes - list all affected entities below and proceed to Part 7

| Note: section 80(1) of the Planning Act 2016 states that the person making the change application must give notice of the proposal and the
details of the change to each affected entity as identified in section 80(2) of the Planning Act 2016.

 

 

 

I
| Affected entity | Pre-request response provided? (where a pre- | Date notice given (where no pre-_ |
request response notice for the application has been | request response provided) |

| given, a copy of the notice must accompany this change |

| application) SIL |

L] No | |

| (_] Yes — pre-request response is attached to |
this change application

| [] No

| [.] Yes — pre-request response is attached to

| this change application

| [] No

| LJ Yes — pre-request response is attached to |
this change application / |

 

 

PART 6 — OTHER CHANGE APPLICATION REQUIREMENTS

Note: To complete this part it will be necessary for you to complete parts of DA Form 1 — Development application details and in some instances parts
of DA Form 2 — Building work details, as mentioned below. These forms are available at aning.« 1.gOov.au.

  

8) Location details - Are there any additional premises included in this change application that were not part of the
original development approval?

| LJ No
| C1 Yes |

 

9) Development details

9.1) Is there any change to the type of development, approval type, or level of assessment in this change
application?
| LJ No
CJ Yes — the completed Sections 1 and 2 of Part 3 (Development details) of DA Form 1 — Development application
details as these sections relate to the new or changed aspects of development are provided with this application.

 

 

9.2) Does the change application involve building work?

C1 No
_] Yes — the completed Part 5 (Building work details) of DA Form 2 — Building work details as it relates to the
change application is provided with this application.

 

10) Referral details - Does the change application require referral for any referral requirements?

Note: The application must be referred to each referral agency triggered by the change application as if the change application was the original
development application including the proposed change.

LINo
| _] Yes — the completed Part 5 (Referral details) of DA Form 1 — Development application details as it relates to the |
change application is provided with this application. Where referral is required for matters relating to building |
k is also completed. |

 

t for building

  

|___work the I

  

11) Information request under Part 3 of the DA Rules

| (J | agree to receive an information request if determined necessary for this change application
| [Ido not agree to accept an information request for this change application |
|

 

Note: By not agreeing to accept an information request |, the applicant, acknowledge.

Page 3
Planning Act Form 5 - Change application form
Version 1.2 — 7 February 2020

Page 4

 

| ¢ — that this change application will be assessed and decided based on the information provided when making this change application and the
| assessment manager and any referral agencies relevant to the change application are not obligated under the DA Rules to accept any
| additional information provided by the applicant for the change application unless agreed to by the relevant parties

| Part 3 of the DA Rules will still apply if the application is an application listed under section 11.3 of the DA Rules.
| Further advice about information requests is contained in the DA Forms Guide: Forms 1 and 2.

1
|

12) Further details

(] Part 7 of DA Form 1 — Development application details is completed as if the change application was a
development application and is provided with this application.

 

PART 7 — CHECKLIST AND APPLICANT DECLARATION

13) Change application checklist

| have identified the:

e responsible entity in 4); and

e for a minor change, any affected entities; and Wes

e for an other change all relevant referral requirement(s) in 10)
Note: See the Planning Regulation 2017 for referral requirements

 

 

 

| For an other change application, the relevant sections of DA Form 1 — Development Yes
application details have been completed and is attached to this application [Not applicable
For an other change application, where building work is associated with the change Yes

application, the relevant sections of DA Form 2 — Building work details have been
completed and is attached to this application

[Not applicable

Supporting information addressing any applicable assessment benchmarks is attached to

 

this application

Note: This includes any templates provided under 23.6 and 23.7 of DA Form 1 — Development application details Yes
that are relevant as a result of the change application, a planning report and any technical reports required by the

relevant categorising instrument(s) (e.g. the local government planning scheme, State Planning Policy, State

Development Assessment Provisions). For further information, see DA Forms Guide: Planning report template

Relevant plans of the development are attached to this development application Zi
Yes

Note: Relevant plans are required to be submitted for all relevant aspects of this change application. For further
information, see DA F Relevar s.

|
|
|
|

 

 

 
   

14) Applicant declaration

 

y making this change application, | declare that all information in this change application is true and correct.
Where an email address is provided in Part 1 of this form, | consent to receive future electronic communications
from the responsible entity and any relevant affected entity or referral agency for the change application where
written information is required or permitted pursuant to sections 11 and 12 of the Electronic Transactions
Act 2001.

Note: It is unlawful to intentionally provide false or misleading information.

| Privacy — Personal information collected in this form will be used by the responsible entity and/or chosen
| assessment manager, any relevant affected entity or referral agency and/or building certifier (including any
| professional advisers which may be engaged by those entities) while processing, assessing and deciding the
| change application.
| All information relating to this change 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:
| e 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
e¢ required by other legislation (including the Right to Information Act 2009); or
|e 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.

 

 

 

Page 4
Planning Act Form 5 - Change application form
Version 1.2 — 7 February 2020

Page 5

PART 8 — FOR COMPLETION OF THE ASSESSMENT MANAGER — FOR OFFICE
USE ONLY

 

Date received: | Reference number(s): |

QLeave notification and payment

 

Note: For completion by assessment manager if applicable

| Description of the work

 

QLeave project number
| Amount paid ($) | | Date paid (dd/mm/yy)
| Date receipted form sighted by assessment manager |

 

Name of officer who sighted the form

 

Page 5
Planning Act Form 5 - Change application form
Version 1.2 — 7 February 2020