DA Form 5- Change Application Form

Note: This includes any templates provided under 23.6 and 23.7 of DA Form 1 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                                                                                          Yes
Note: Relevant plans are required to be submitted for all relevant aspects of this
change application. For further information, see DA Forms Guide: Relevant plans.

14) Applicant declaration
    By making this change application, I declare that all information in this change application is true and correct.
    Where an email address is provided in Part 1 of this form, I 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:
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 8 – FOR OFFICE USE ONLY
Date                                         Reference number(s):
received:


QLeave notification and payment
Note: For completion by assessment manager if applicable
Description of the work
QLeave project number
Amount paid ($)
Date paid
Date receipted form sighted by assessment
manager
Name of officer who sighted the form




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                                                                                         Planning Act Form 5 - Change application form
                                                                                                         Version 1.1 — 22 JUNE 2018