Change to a DA (Caterers Shop to Retail Type 2 Shop & Salon - Hairdresser) - 51901.4863.07

                                                                                       Department of Infrastructure, Local Government and Planning




9) Referral details - Do any aspects of the change application require referral for any referral requirements?
Note me applicatlOlJ ml/;jl bp. It:!tmed 10 t:ClL:iJ feferral aqencv trlqqered by the chanqe appliC8fJOn as If the clMnge applicatiOn was tile angmal
development     application    IFlcludmg the proposed change

 lIli
 D Ves - the completed Sections 1 and 2 of Part 5 (Referral details) of DA Form 1 as it relates to the change application is
 provided with this application. Where referral is required for mailers relating to building work the referral checklist for
 building work is also completed.



        I agree to receive an information request if determined necessary for this change application
 D I do not agree to accept an information request for this change application
 Note: By not agreeing to accept an infonnation request I, the applicant, acknowledge:
 • that this change application will be assessed and decided based on the infonnation 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 infonnation 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 infonnation requests is contained in the DA Forms Guide.




 D Part 7 of DA Form 1 is completed as if the change application was a development application and is provided with this
 application.


PART 6 - CHECKLIST AND APPLICANT DECLARATION

 12) change application checklist
 I have identified the:
         •     responsible entity in 3); and
                                                                                                                      ciVes
         •     for a minor change, any affected entities; and

         •     for an 'other' change all relevant referral requirement(s)              in 9)
 Note: See the Planning Regulation 2017 for referral requirements
  For an 'other' change application, the relevant sections of DA Form 1 - Development                                 DVes
  detailshave been completed and is allached to this application                                                      C1Not applicable

  For an 'other' change application, where building work is associated with the change                                DVes
  application, the relevant sections of Form 2 - Building work details have been                                      B'Not     applicable
  completed and is allached to this application
  Supporting information addressing any applicable assessment benchmarks is attached
  to this application
  Note: This includes any templates provided under 23.6) of DA Fonn 1 that are relevant as a
  resull of the change application, a planning report and any technical reports required by the
                                                                                                                       DVes
  relevant categorising instrument(s) (e.g. the local govemment planning scheme, State Planning
  Policy, State Development Assessment Provisions). For further infonnation, see DA Fonns
  Guide: Planning report template.
  Relevant plans of the development are allached to this development application
  Note: Relevant plans are required to be submitted for all relevant aspects of this change                            DVes
  application. For further infonnation, see DA Fonns Guide: Relevant plans.




          y 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 wrillen
     information is required or permitted pursuant to sections 11 and 12 of the Electronic Transactions Act 2001.
     Note: /I is unlawful     to intentionally   provide false or misleading infonnation.

                                                                                                                                                        Page 3
                                                                                                              Planning Act Form 5 - Change application    form
                                                                                                                                     Version 1.0-3 July 2017