DA Form 5 Change application form

PART 8 – FOR OFFICE USE ONLY

Date                                         Reference number(s):
received:


QLeave notification and payment
Note: For completion by assessment manager if applicable
                                                           ALTERATIONS & ADDITIONS TO EXISTING DWELLING UNIT TO
Description of the work                                    CONVERT AN EXISTING VERANDAH INTO A HABITAL ROOM &
                                                           INCREASE GFA.
QLeave project number                                      N/A
Amount paid ($)                                            N/A
Date paid                                                  N/A
Date receipted form sighted by assessment
                                                           N/A
manager
Name of officer who sighted the form                       N/A




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