Attachment 1_DA Form_5.pdf

 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 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


[OCR of page images]
 

 

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 COMPLETION OF THE ASSESSMENT MANAGER — FOR OFFICE

USE ONLY

 

 

Date received: [tid 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