Revised DA Form 1 & Plan

Page 2

PART 2 — LOCATION DETAILS

3) Location of the premises (complete 3.1) or 3.2), and 3.3) as applicable)
Note: Provide details below and attach a site plan for any or all premises part of the development application. For further information, see DA

Forms Guide: Relevant plans.
3.1) Street address and lot on plan

 

 

 

 

 

 

 

 

CJ Street address AND lot on plan (ail lots must be listed), or
C] Street address AND lot on plan for an adjoining or adjacent property of the premises (appropriate for development in
water but adjoining or adjacent to land e.g. jetty, pontoon. All lots must be listed).
Unit No. | Street No. Street Name and Type Suburb
~ ew wv) 4 f
4 2% AO Wha Tow OPN COORIVERE -
Postcode | Lot No. Plan Type and Number (e.g. RP, SP) Local Government Area(s)
Peed | 90 SPSS 22/F VIER
Unit No. | Street No. | Street Name and Type Suburb
b)
Postcode | Lot No. Plan Type and Number (e.g. RP, SP) Local Government Area(s)

 

 

 

 

 

 

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) |

CM Clwess4
1 Gpag4

(J Other:

 

 

 

 

 

LJ Coordinates of premises by easting and northing

 

 

 

 

Easting(s) Northing(s) Zone Ref. | Datum Local Government Area(s) (if applicable)
O54 | Dwese4
(155 | L] GDA94
C156 CJ Other:

 

 

3.3) Additional premises

 

LJ Additional premises are relevant to this development application and the details of these premises have been
attached in a schedule to this development application

CJ Not required

 

4) Identify any of the following that apply to the premises and provide any relevant details

 

LJ In or adjacent to a water body or watercourse or in or above an aquifer
Name of water body, watercourse or aquifer: |

 

 

CJ On strategic port land under the Transport Infrastructure Act 1994

 

Lot on plan description of strategic port land:
Name of port authority for the lot:
CJ Ina tidal area

 

 

 

Name of local government for the tidal area (if applicable):

 

Name of port authority for tidal area (if applicable):
LJ On airport land under the Airport Assets (Restructuring and Disposal) Act 2008
Name of airport:

 

 

 

 

 

 

Page 2
DA Form 1 — Development application details
Version 1.3— 28 September 2020

Page 3

 

CJ Listed on the Environmental Management Register (EMR) under the Environmental Protection Act 1994
EMR site identification: |
LJ Listed on the Contaminated Land Register (CLR) under the Environmental Protection Act 1994
CLR site identification: |

 

 

 

 

 

 

5) Are there any existing easements over the premises?

Note: Easement uses vary throughout Queensland and are to be identified correctly and accurately. For further information on easements and
how they may affect the proposed development, see DA Forms Guide.

 

L] Yes — All easement locations, types and dimensions are included in plans submitted with this development
application
No

 

PART 3 — DEVELOPMENT DETAILS

Section 1 — Aspects of development

6.1) Provide details about the first development aspect

a) What is the type of development? (tick only one box)

 

 

 

f
CJ Material change of use ~—_[_] Reconfiguring a lot 7 Operational work LJ Building work
b) What is the approval type? (tick only one box)
[if Development permit CJ Preliminary approval L] Preliminary approval that includes a variation approval

 

Cc) What is the level of assessment?

 

[W Code assessment LJ Impact assessment (requires public notification)

 

d) Provide a brief description of the proposal (e.g. 6 unit apartment building defined as multi-unit dwelling, reconfiguration of 1 lot into 3
lots):
; 5 : ~ 5
SCOVYY chKOsa VB
e) Relevant plans

Note: Relevant plans are required to be submitted for all aspects of this development application. For further information, see DA Forms quide:
Relevant plans.

CJ Relevant plans of the proposed development are attached to the development application
6.2) Provide details about the second development aspect

 

 

 

 

a) What is the type of development? (tick only one box)

 

 

 

i
CJ Material change of use —_[_] Reconfiguring a lot [™ Operational work C1 Building work
b) What is the approval type? (tick only one box)
[WDevelopment permit L] Preliminary approval CJ Preliminary approval that includes a variation approval

 

c) What is the level of assessment?

 

M Code assessment L] Impact assessment (requires public notification)

 

d) Provide a brief description of the proposal (e.g. 6 unit apartment building defined as multi-unit dwelling, reconfiguration of 1 lot into 3
lots): :

SLOVO COIR
e) Relevant plans

Note: Relevant plans are required to be submitted for all aspects of this development application. For further information, see DA Forms Guide:
Relevant plans.

(J Relevant plans of the proposed development are attached to the development application

 

 

 

 

6 Aaditional aspe oj developme

(J Additional aspects of development are relevant to this development application and the details for these aspects
that would be required under Part 3 Section 1 of this form have been attached to this development application

CJ Not required

 

 

Page 3
DA Form 1 — Development application details
Version 1.3— 28 September 2020

Page 4

x


[OCR of page images]
Section 2 — Further development details

7) Does the proposed development application involve any of the following?

 

 

 

 

Material change of use CJ Yes — complete division 1 if assessable against a local planning instrument
Reconfiguring a lot C1 Yes — complete division 2

Operational work Yes — complete division 3

Building work CJ Yes — complete DA Form 2 — Building work details

 

 

 

Division 1 — Material change of use
Note: This division is only required to be completed if any part of the development application involves a material change of use assessable against a

local planning instrument.
8.1) Describe the proposed material change of use

 

 

 

 

 

 

 

 

 

Provide a general description of the Provide the planning scheme definition | Number of dwelling | Gross floor

proposed use (include each definition in a new row) units (if applicable) area (m?)
(if applicable)

8.2) Does the proposed use involve the use of existing buildings on the premises?

LC Yes

[No

 

 

Division 2 — Reconfiguring a lot
Note: This division is only required to be completed if any part of the development application involves reconfiguring a lot.
9.1) What is the total number of existing lots making up the premises?

 

9.2) What is the nature of the lot reconfiguration? (tick all applicable boxes)

 

 

 

 

LJ Subdivision (complete 10) LJ Dividing land into parts by agreement (complete 11))
LJ Boundary realignment (complete 12)) LD Creating or changing an easement giving access to a lot
from a constructed road (complete 13))

 

10) Subdivision

10.1) For this development, how many lots are being created and what is the intended use of those lots:

 

Intended use of lots created Residential Commercial Industrial Other, please specify:

 

 

 

Number of lots created
10.2) Will the subdivision be staged?
L] Yes — provide additional details below

LC No

How many stages will the works include?

 

 

 

What stage(s) will this development application
apply to?

 

 

 

 

Page 4
DA Form 1 — Development application details
Version 1.3— 28 September 2020

Page 5

11) Dividing land into parts by agreement — how many parts are being created and what is the intended use of the

 

jee lasieg
Intended use of parts created Residential Commercial Industrial Other, please specify:

 

 

 

 

 

 

Number of parts created

 

12) Boundary realignment

 

12.1) What are the current and proposed areas for each lot comprising the premises?
Current lot Proposed lot

 

Lot on plan description Area (m?) Lot on plan description Area (m?)

 

 

 

 

 

 

 

12.2) What is the reason for the boundary realignment?

 

 

13) What are the dimensions and nature of any existing easements being changed and/or any proposed easement?

 

(attach schedule if there are more than two easements)

Existing or Width (m) | Length(m) | Purpose of the easement? (e.g. Identify the land/lot(s)
proposed? pedestrian access) benefitted by the easement

 

 

 

 

 

 

 

 

 

Division 3 — Operational work
Note: This division is only required to be completed if any part of the development application involves operational work.
14.1) What is the nature of the operational work?

CJ Road work CJ] Stormwater CJ Water infrastructure
CJ Drainage work (Earthworks LJ Sewage infrastructure
CJ Landscaping L] Signage LJ Clearing vegetation
ff] Other — please specify: Seno DW

14.2) Is the operational work necessary to facilitate the creation of new lots? (e.g. subdivision)

 
    

  
 
   
     
  

 

    
  
    
      

  

LJ Yes — specify number of new lots:

M4 No

14.3) What is the monetary value of the proposed operational work? (include GST, materials and labour)

$ 3000
PART 4 — ASSESSMENT MANAGER DETAILS

 

 

  

 

15) Identify the assessment manager(s) who will be assessing this development application

Cok Councic
16) Has the local government agreed to apply a superseded planning scheme for this development application?

CJ Yes — a copy of the decision notice is attached to this development application

LJ The local government is taken to have agreed to the superseded planning scheme request — relevant documents
attached

M No

 

 

Page 5
DA Form 1 — Development application details
Version 1.3— 28 September 2020

Page 6

PART 5 — REFERRAL DETAILS

17) Does this development application include any aspects that have any referral requirements?

 

Note: A development application will require referral if prescribed by the Planning Regulation 2017.

No, there are no referral requirements relevant to any development aspects identified in this development
application — proceed to Part 6

Matters requiring referral to the Chief Executive of the Planning Act 2016:

LJ Clearing native vegetation

(J Contaminated land (unexploded ordnance)

LJ Environmentally relevant activities (ERA) (only if the ERA has not been devolved to a local government)

C Fisheries — aquaculture

CJ Fisheries — declared fish habitat area

LC Fisheries — marine plants

LJ Fisheries — waterway barrier works

(] Hazardous chemical facilities :

LJ Heritage places — Queensland heritage place (on or near a Queensland heritage place)

(J Infrastructure-related referrals — designated premises

LJ Infrastructure-related referrals — state transport infrastructure

(J Infrastructure-related referrals — State transport corridor and future State transport corridor

(J Infrastructure-related referrals — State-controlled transport tunnels and future state-controlled transport tunnels
(J Infrastructure-related referrals — near a state-controlled road intersection

LC Koala habitat in SEQ region — interfering with koala habitat in koala habitat areas outside koala priority areas
LH Koala habitat in SEQ region — key resource areas

CJ Ports — Brisbane core port land — near a State transport corridor or future State transport corridor
LJ Ports — Brisbane core port land — environmentally relevant activity (ERA)

(J Ports — Brisbane core port land — tidal works or work in a coastal management district

LJ Ports — Brisbane core port land — hazardous chemical facility

(J Ports — Brisbane core port land — taking or interfering with water

LJ Ports — Brisbane core port land — referable dams

CJ Ports — Brisbane core port land — fisheries

CJ Ports — Land within Port of Brisbane’s port limits (below high-water mark)

LJ SEQ development area

C1 SEQ regional landscape and rural production area or SEQ rural living area — tourist activity or sport and
recreation activity

LJ SEQ regional landscape and rural production area or SEQ rural living area — community activity
L] SEQ regional landscape and rural production area or SEQ rural living area — indoor recreation
LJ SEQ regional landscape and rural production area or SEQ rural living area — urban activity

LJ SEQ regional landscape and rural production area or SEQ rural living area — combined use
LJ Tidal works or works in a coastal management district

LJ Reconfiguring a lot in a coastal management district or for a canal

LJ Erosion prone area in a coastal management district

LJ Urban design

LJ Water-related development — taking or interfering with water

LJ Water-related development — removing quarry material (from a watercourse or lake)

LJ Water-related development — referable dams

L] Water-related development —levees (category 3 levees only)

(J Wetland protection area

Matters requiring referral to the local government:

LJ Airport land
CJ Environmentally relevant activities (ERA) (only if the ERA has been devolved to local government)

 

 

 

 

 

Page 6
DA Form 1 — Development application details
Version 1.3— 28 September 2020

Page 7

LJ Heritage places — Local heritage places
Matters requiring referral to the Chief Executive of the distribution entity or transmission entity:
(CJ Infrastructure-related referrals — Electricity infrastructure

 

 

Matters requiring referral to:

e The Chief Executive of the holder of the licence, if not an individual
e The holder of the licence, if the holder of the licence is an individual
(J Infrastructure-related referrals — Oil and gas infrastructure

 

Matters requiring referral to the Brisbane City Council:

CJ] Ports — Brisbane core port land

Matters requiring referral to the Minister responsible for administering the Transport Infrastructure Act 1994:
CJ Ports — Brisbane core port land (where inconsistent with the Brisbane port LUP for transport reasons)

LJ Ports — Strategic port land

Matters requiring referral to the relevant port operator, if applicant is not port operator:

CJ Ports — Land within Port of Brisbane’s port limits (below high-water mark)

 

 

 

Matters requiring referral to the Chief Executive of the relevant port authority:
CJ Ports — Land within limits of another port (below high-water mark)

 

Matters requiring referral to the Gold Coast Waterways Authority:
CJ Tidal works or work in a coastal management district (in Gold Coast waters)

 

Matters requiring referral to the Queensland Fire and Emergency Service:
C Tidal works or work in a coastal management district (involving a marina (more than six vessel berths))

18) Has any referral agency provided a referral response for this development application?

CJ Yes - referral response(s) received and listed below are attached to this development application
[No

Referral requirement Referral agency Date of referral response

 

 

 

 

 

 

 

 

Identify and describe any changes made to the proposed development application that was the subject of the

referral response and this development application, or include details in a schedule to this development application
(if applicable).

 

 

 

 

PART 6 — INFORMATION REQUEST

19) information request under Part 3 of the DA Rules

 

[4 | agree to receive an information request if determined necessary for this development application
LJ | do not agree to accept an information request for this development application
Note: By not agreeing to accept an information request |, the applicant, acknowledge:

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

e 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.

 

Page 7
DA Form 1 — Development application details
Version 1.3— 28 September 2020

Page 8

PART 7 — FURTHER DETAILS

20) Are there any associated development applications or current approvals? (e.g. a preliminary approval)
LJ Yes — provide details below or include details in a schedule to this development application

XJ No

 

 

List of approval/development Reference number Date Assessment
application references manager

C1 Approval
(] Development application

LI Approval
(J Development application

 

 

 

 

 

 

21) Has the portable long service leave levy been paid? (only applicable to development applications involving building work or

 

operational work)

CJ Yes — a copy of the receipted QLeave form is attached to this development application

CJ No - |, the applicant will provide evidence that the portable long service leave levy has been paid before the
assessment manager decides the development application. | acknowledge that the assessment manager may
give a development approval only if | provide evidence that the portable long service leave levy has been paid

EX Not applicable (e.g. building and construction work is less than $150,000 excluding GST)
Amount paid Date paid (dd/mm/yy) QLeave levy number (A, B or E)
$

 

 

 

 

 

22) Is this development application in response to a show cause notice or required as a result of an enforcement
notice?

 

CI Yes — show cause or enforcement notice is attached

[EL No

 

 

 

23) Further legislative requirements
Environmentally relevant activities

23.1) Is this development application also taken to be an application for an environmental authority for an
Environmentally Relevant Activity (ERA) under section 115 of the Environmental Protection Act 1994?

 

LJ Yes — the required attachment (form ESR/2015/1791) for an application for an environmental authority
accompanies this development application, and details are provided in the table below

SX] No

Note: Application for an environmental authority can be found by searching “ESR/2015/1791” as a search term at www.qld.gov.au. An ERA
requires an environmental authority to operate. See www.business.qld.gov.au for further information.

Proposed ERA number: Proposed ERA threshold:
Proposed ERA name:

 

 

 

 

CJ Multiple ERAs are applicable to this development application and the details have been attached in a schedule to
this development application.

Hazardous chemical facilities

 

23.2) Is this development application for a hazardous chemical facility?

(1 Yes — Form 69: Notification of a facility exceeding 10% of schedule 15 threshold is attached to this development
application

LI No

Note: See www.business.qld.gov.au for further information about hazardous chemical notifications.

 

 

 

Page 8
DA Form 1 — Development application details
Version 1.3— 28 September 2020

Page 9

Clearing native vegetation

23.3) Does this development application involve clearing native vegetation that requires written confirmation that
the chief executive of the Vegetation Management Act 1999 is satisfied the clearing is for a relevant purpose under
section 22A of the Vegetation Management Act 1999?

C1 Yes — this development application includes written confirmation from the chief executive of the Vegetation
Management Act 1999 (s22A determination)

[1 No

Note: 1. Where a development application for operational work or material change of use requires a s22A determination and this is not included,
the development application is prohibited development.
2. See https./www.qld.gov.au/environment/land/vegetation/applying for further information on how to obtain a s22A determination.

Environmental offsets

23.4) Is this development application taken to be a prescribed activity that may have a significant residual impact on
a prescribed environmental matter under the Environmental Offsets Act 2014?

LJ Yes — | acknowledge that an environmental offset must be provided for any prescribed activity assessed as
having a significant residual impact on a prescribed environmental matter

LJ No

Note: The environmental offset section of the Queensland Government's website can be accessed at www.qld.gov.au for further information on
environmental offsets.

Koala habitat in SEQ Region

23.5) Does this development application involve a material change of use, reconfiguring a lot or operational work
which is assessable development under Schedule 10, Part 10 of the Planning Regulation 2017?

CJ Yes — the development application involves premises in the koala habitat area in the koala priority area

LJ Yes — the development application involves premises in the koala habitat area outside the koala priority area

LINo

Note: /f a koala habitat area determination has been obtained for this premises and is current over the land, it should be provided as part of this
development application. See koala habitat area guidance materials at www.des.q/d.gov.au for further information.

Water resources

23.6) Does this development application involve taking or interfering with underground water through an
artesian or subartesian bore, taking or interfering with water in a watercourse, lake or spring, or taking
overland flow water under the Water Act 2000?

 

LJ Yes — the relevant template is completed and attached to this development application and | acknowledge that a
relevant authorisation or licence under the Water Act 2000 may be required prior to commencing development

LJ No

Note: Contact the Department of Natural Resources, Mines and Energy at www.dnrme.qid.qov.au for further information.
DA templates are available from https://planning.dsdmip.qld.gov.au/. If the development application involves:

e Taking or interfering with underground water through an artesian or subartesian bore: complete DA Form 1 Template 1
° Taking or interfering with water in a watercourse, lake or spring: complete DA Form1 Template 2

e Taking overland flow water: complete DA Form 1 Template 3.

Waterway barrier works

   

23.7) Does this application involve waterway barrier works?

L] Yes — the relevant template is completed and attached to this development application

L] No

DA templates are available from https://olanning.dsdmip.qld.gov.au/. For a development application involving waterway barrier works, complete
DA Form, 1 Template 4.

 

Marine activities

23.8) Does this development application involve aquaculture, works within a declared fish habitat area or
removal, disturbance or destruction of marine plants?

 

(1 Yes - an associated resource allocation authority is attached to this development application, if required under
the Fisheries Act 1994

LINo

Note: See guidance materials at www.daf.qld.gov.au for further information.

 

 

Page 9
DA Form 1 — Development application details
Version 1.3— 28 September 2020

Page 10

Quarry materials from a watercourse or lake

23.9) Does this development application involve the removal of quarry materials from a watercourse or lake
under the Water Act 2000?

C1 Yes — | acknowledge that a quarry material allocation notice must be obtained prior to commencing development

C1 No

Note: Contact the Department of Natural Resources, Mines and Energy at www.dnrme.gid.gov.au and www.business.qid.gov.au for further
information.

Quarry materials from land under tidal waters

23.10) Does this development application involve the removal of quarry materials from land under tidal water
under the Coastal Protection and Management Act 1995?

 

 

LC] Yes — | acknowledge that a quarry material allocation notice must be obtained prior to commencing development
[1 No

Note: Contact the Department of Environment and Science at www.des.q/d.gov.au for further information.
Referable dams

23.11) Does this development application involve a referable dam required to be failure impact assessed under
section 343 of the Water Supply (Safety and Reliability) Act 2008 (the Water Supply Act)?

 

LO Yes - the ‘Notice Accepting a Failure Impact Assessment’ from the chief executive administering the Water
Supply Act is attached to this development application

LI No

Note: See guidance materials at www.dnrme.gid.gov.au for further information.
Tidal work or development within a coastal management district

   

23.12) Does this development application involve tidal work or development in a coastal management district?

L Yes - the following is included with this development application:

(1 Evidence the proposal meets the code for assessable development that is prescribed tidal work (only required
if application involves prescribed tidal work)

C1 A certificate of title
LI No

Note: See guidance materials at www.des.qi/d.gov.au for further information.

Queensland and local heritage places

23.13) Does this development application propose development on or adjoining a place entered in the Queensland
heritage register or on a place entered in a local government's Local Heritage Register?

 

LJ Yes — details of the heritage place are provided in the table below

LI No

Note: See guidance materials at www.des.qid.gov.au for information requirements regarding development of Queensland heritage places.

 

 

Name of the heritage place:
Brothels

 

23.14) Does this development application involve a material change of use for a brothel?

1 Yes — this development application demonstrates how the proposal meets the code for a development
application for a brothel under Schedule 3 of the Prostitution Regulation 2014

LJ No
Decision under section 62 of the Transport Infrastructure Act 1994

23.15) Does this development application involve new or changed access to a state-controlled road?

 

LJ Yes — this application will be taken to be an application for a decision under section 62 of the Transport
Infrastructure Act 1994 (subject to the conditions in section 75 of the Transport Infrastructure Act 1994 being
satisfied)

LINo

 

 

Page 10
DA Form 1 — Development application details
Version 1.3— 28 September 2020

Page 11

x




x


[OCR of page images]
Walkable neighbourhoods assessment benchmarks under Schedule 12A of the Planning Regulation

23.16) Does this development application involve reconfiguring a lot into 2 or more lots in certain residential zones
(except rural residential zones), where at least one road is created or extended?

 

LJ Yes — Schedule 12A is applicable to the development application and the assessment benchmarks contained in
schedule 12A have been considered

LI No

Note: See guidance materials at www.planning.dsdmip.qid.gov.au for further information.

 

PART 8 — CHECKLIST AND APPLICANT DECLARATION

24) Development application checklist

| have identified the assessment manager in question 15 and all relevant referral
requirement(s) in question 17 Yes
Note: See the Planning Regulation 2017 for referral requirements

 

 

If building work is associated with the proposed development, Parts 4 to 6 of DAForm2-— []Yes
Building work details have been completed and attached to this development application M Not applicable

 

Supporting information addressing any applicable assessment benchmarks is with the
development application

Note: This is a mandatory requirement and includes any relevant templates under question 23, a planning report Yes
and any technical reports required by the relevant categorising instruments (e.g. local government planning

schemes, 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

 

 

Note: Relevant plans are required to be submitted for all aspects of this development application. For further Yes

information, see DA Forms Guide: Relevant plans.

The portable long service leave levy for QLeave has been paid, or will be paid before a Dyes
development permit is issued (see 27) Not applicable

 

 

25) Applicant declaration

[By making this development application, | declare that all information in this development application is true and

correct

here an email address is provided in Part 1 of this form, | consent to receive future electronic communications
from the assessment manager and any referral agency for the development 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 assessment manager and/or chosen

assessment manager, any relevant referral agency and/or building certifier (including any professional advisers

which may be engaged by those entities) while processing, assessing and deciding the development application.

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:

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 11
DA Form 1 — Development application details
Version 1.3— 28 September 2020

Page 12

PART 9 —- FOR COMPLETION OF THE ASSESSMENT MANAGER — FOR OFFICE

USE ONLY

 

Date received: [sd Reference number(s): |

 

Notification of engagement of alternative assessment manager

Prescribed assessment manager

|

 

Name of chosen assessment manager

 

Date chosen assessment manager engaged

 

Contact number of chosen assessment manager

 

Relevant licence number(s) of chosen assessment
manager

 

Description of the work

QLeave notification and payment
Note: For completion by assessment manager if applicable

 

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 12
DA Form 1 — Development application details
Version 1.3— 28 September 2020

Page 13

Page 14