09/0951 - MCU - Detached House [As Published] · 132009.951

INTEGRATED PLANNING ACT 1997 Part A, Version 3.1, 3 March 2008

2. _ Identify if any of the following apply to the premises by completing Tables D, E, or F. (Note: in most instances, the premises will not involve any of the
following characteristics, however some applications may involve one or more of these characteristics - complete only if applicable)

Table D Complete if the Premises are adjacent fo or associated with a water body, watercourse or aquifer (e.g. river, creek, lake, canal)

 

 

1. “TaKe Coo HARARA

Table E Complete if the premises are on Strategic Port Land under the Transport Infrastructure Act 1994
= =.=. Loton plan description -for strategic port land . =-Port authority forthelot <=".

 

 

 

 

   

 

 

Table F Complete if the premises are in tidal water

 

=. Name of local government for the tidal area (/f applicable) Name of port authority-for the tidal area (if applicable)

1. Gumerut GoAst REGIONAL Council

3. Indicate the total area of the premises on which the development is proposed: (Wote: The total area may include land both above and below water)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total area of premises (land on which the development is proposed)
SlIoOl6llolo Lame OC hectares (+ appiicabte uniy
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.)
SrePp
5. Are there any existing easements on the premises? (e.g. for vehicular access, electricity, overland flow, water etc.)
@ No O Yes - Ensure the type, location and dimensions of each easement are included in plans, submitted with the application
oe cote ee ce tae ap me 4
Proposal details = : 3 . a ee ‘
6. Brief description of the proposal: (e.g. 6 unit apartment building, 30 lot residential subdivision, a bore, aquaculture etc.)
DwelLuna@
7. Does the proposal "We building work or operational work (including any services) on the premises?
O No Yes - Ensure the nature, location and dimensions of the proposed works are included in plans, submitted with the application
—— . ”
| Resource entitlement (applicable) “= further information is provided in the advice section at the end of the form «=. wR wo i

 

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.)

No - Goto Q9 O 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 Q9 ~ go to the next section.

Nature of State-owned resourct

TableG —_ |Nature of evidence required

Allocation/entitlement
i reference number

 

 

 

 

   

~ State Government  ;:) : Date of Date of .

_ Name of authorising officer: | . -” Position of authorising officer: » © Department 22! ~ 4]! issue |. [email protected] ner’s consent (if. fit applicable) ~ ~ further information is provided in the advice section at the end of thé form =

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 Managemen Act 1995, or work on rail corridor land defined under the
Transport Infrastructure Act 1994 - provide details for each owner on a separate row, of on an attachment to this form if applicable.

 

  

   

  
 

       

 

Table H remises Owner's namel Delails of the premises owned |. “| Date consent
* and postal address reel iption) * was obtained
1, | Donna JEFFERIES 25 Uruuica Paraoe

Po Bex 166 Boreen, Pew
Burr HEROS @ 4659 | Lot GO RP5IZI6

 

 

 

 

 

 

 

 

33/2/09
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* owners 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, $127 of the Corporations Act 2007 (Cwealth) details how a
company may sign as owner. Templates for the provision of owner's consent are available on the IPA website .

Onan 9