001A6E4B.001

INTEGRATED PLANNING ACT 1997                                                                                                Part A, Version 3.1, 3 March 2008
  %       Table D    Complete if the premises are adjacent to or associated with a water body, watercourse or aquifer (e.g. river. creek, take, canal)
                                                                      Name of water body, watercourse or aquifer (if known)          .
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          Table E    Complete if the premises are on Strategic Port Land under the Transport Infrastructure Act 1994
                                        Lot on plan description for strategic port land.  .                         ~  Port Authority for the fot             a
                    Ee
          Table F    Complete if the premises are in tidal water
                             _    Name of local goverment for the tidal area (if applicable)   |         Name of port authority for the tidal area (if applicable)
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          3.     Indicate the total area of the premises on which the development is proposed: (Note: The total area may include land both above and below water)
                :                       Total area of premises
                531.00              [X] m? [_] hectares       (Tick applicable unit)
           Existing use of the premises                                                              _.                         :
          4.     Current use/s of the premises: (e.g. vacant land, house, townhouses, apartment building, shop, service station, school, sugar cane farming etc.)
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           5.    Are there any existing easements on the premises? (e.g. for vehicular access, electricity, overland flow, water elc.)?
                X] No      C] Yes - Ensure the type, location and dimensions of each easement are included in plans, submitted with the application
          Proposal details               ~                  Te]
           6.    Brief description of the proposal (e.g. 6 unit apartment building, 30 tot residential subdivision, a bore, aquaculture)

           demolition and removal of existing dwelling and construction of a new dwelling

           7.    Does the poposal include new buildings or operational work (including any services) on the premises?
                 [] No        xX Yes - Ensure the nature, location and dimensions of the proposed works are included in plans, submitted with the application
           Resource entitlement (if applicable) _- further information is provided in the advice section at the end of the form a          a        -            m
           8.   Does the application involve taking or interfering with a State resource and therefore require a resource entitlement? (e.g. the application
                involves State land (leased and freehold), declared Fish Habitat areas, taking quarry material, taking or interfering with water under the Water Act 2000, etc.)
                 x No -GatoQa9            [| Yes - Complete Table G - provide details for each evidence required on a separate row, if applicable. Evidence of resource
                                                      allocation or entitlement must be submitted with the application. You do not need to answer QS - go to the next section.
           Owner's consent (it applicable) _- further information is. provided in the advice section at the end of the form "= “                               2
           9.   Complete Table H for applications involving a material change of use; reconfiguration of a lot; work on land below high-water mark and
                not within a canal as defined under the Coastal Protection and Management Act 1995; or work on rail corridor {and defined under the
                Transport infrastructure Act 1994 - provide details for each owner on a separate row, or on an attachment to this form if applicable.
                                  ‘Premises Owner's name/s                 ’ Details of the premises owned :                          oo,            Date consent
           Table H                ;     and postal address:     «|.      (street address or lot'on plan description} :   Owner's signature        _ was obtained

            * Owner's signature cannot be provided on the form if you intend to submit the application electronically. Owner's consent must be provided to the assessment manager on an
             attachment containing appropriate written documentation of the owner's consent, If the owner Is a company, 8127 of the Corporations Act 2001 (Cwealth) details how a
             company may sign as owner. Templates for the provision of owner's consent are available on the IPA website .
            Attachments and supporting information’ (Compiete Table | - Use a Séparate row for each type of attachment or information, including information required ©
            under this Part) Please ensure all documeniation submitted. with.this form, including other Parts of Form.1, or owner's consent, él¢, are sécurely attached to this Part of the Form.
                                       Description of attachment or information                 Ti         Nes         —          a            :          ‘del
                                  :                                    "           APES            tle. (if applicable)                         Method of delivery to
            Table |                (e.g. Part C af Form 1, owner's consent, evidence of resource : |" ue.   ‘         .           . Date-      .
                                         allcation/entitlement, plans, drawings, reports) (eg. General Authority. James StreetTrafilé Report)  | assessment manager
                               | Attachment 1                                        Superseded scheme                      po                 over the counter