152008.750.3 Change to existing approval/Extension to relevant period

4. Location of the premises

 

 

 

Unit No. StreetNo 2p), Steet Bin, b Puracinr Rol
Suburb LODeTthALA GA State > Postcode
Lot no. Plan type & plan no.

az RP Zooey

 

 

 

 

 

 

opm OXela lige cute wANe (Ua lect)
Was there one or more concurrence agencies involved in the original approval? O No
O Yes-provide details below

Note — Under s372 of the Sustainable Planning Act 2009 the person making the request is required to give a copy of this request to alt
concurrence agencies.

 

 

Concurrence Agency Date copy given

 

 

 

 

 

6. Pre-request response notice

Has a pre-request response been given by a relevant entity (e.g. a concurrence agency) for this request?
No [EI Yes

If yes, please attach a copy of the notice.

 

 

 

 

7. Owner’s consent

Is the owner's consent required for this request? O No
O Yes-— complete either Table A or Table B below
Note — If more than one owner of the land all owners’ details are required

 

 

 

 

Table A — owner’s consent previded on form Table B — owner’s consent provided on form
1A Yee.
7 tVOA
Wow Ween €
lWe, the above-mentioned owner/s of the land, consent O The owner's written consent is attached.
to the making of this request.

 

Owner's name/s

 

Owner's name/s

 

 

 

 

 

 

 

Signature/s

 

Date

 

 

 

 

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