DA Form 5 Change application form

    ☐ I do not agree to accept an information request for this change application
    Note: By not agreeing to accept an information request I, the applicant, acknowledge:
•   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 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 application details have been completed and is attached to this
                                                                                                        ☐ Yes
    application                                                                                          Not applicable
    For an ‘other’ change application, where building work is associated with the
    change application, the relevant sections of DA Form 2 – Building work details
                                                                                                        ☐ Yes
    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 that are
    relevant as a result of the change application, a planning report and any technical reports         ☐ Yes
    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            Yes
    application. For further 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.




                                                                                                                                  Page 4
                                                                                            Planning Act Form 5 - Change application form
                                                                                                            Version 1.1 — 22 JUNE 2018