Minor Change Application - 14-16 Reserve St, Pomona - MCU22-0097.02

        •   that this change application will be assessed and decided based on the information 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 information 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 information requests is contained in the DA Forms Guide: Forms 1 and 2.


        12) Further details
            Part 7 of DA Form 1 – Development application details is completed as if the change application was a
            development application and is provided with this application.

     PART 7 – CHECKLIST AND APPLICANT DECLARATION

        13) Change application checklist
        I have identified the:
        • responsible entity in 4); and
        • for a minor change, any affected entities; and                                                                         Yes
        • for an other change all relevant referral requirement(s) in 10)
        Note: See the Planning Regulation 2017 for referral requirements
        For an other change application, the relevant sections of DA Form 1 – Development                                        Yes
        application details have been completed and is attached to this application                                              Not applicable
        For an other change application, where building work is associated with the change                                       Yes
        application, the relevant sections of DA Form 2 – Building work details have been
        completed and is attached to this application                                                                            Not applicable

        Supporting information addressing any applicable assessment benchmarks is attached to
        this application
        Note: This includes any templates provided under 23.6 and 23.7 of DA Form 1 – Development application details            Yes
        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
        Note: Relevant plans are required to be submitted for all relevant aspects of this change application. For further       Yes
        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.


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                                                                                                               Planning Act Form 5 - Change application form
                                                                                                                              Version 1.2 — 7 February 2020
Document Set ID: 24937252
Version: 1, Version Date: 09/07/2026