Development Application - Part 1 of 1 · OPW12/0258

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Privacy-the information collected in this form will be used by the Department of Infrastructure and Planning (DIP)in
accordance with the processing and assessment of your application. Your personal details will not be disclosed for a purpose
outside of the IDAS process, except where required by legislation (including the Right to Information Act 2009) or as required

by Parliament. This information may be stored in a departmental database. The information collected will be retained as
required by the Public Records Act 2002.



OFFICE USE ONLY

 Date received
                     I                                    I Reference numbers      I
NOTIFICATION OF ENGAGEMENT OF A PRIVATE CERTIFIER

 To
       I                                I   (000&I have bee’ e’gaged as the pdvate mime’fo’the buHd’,g wo" ,efmed
                                            to in this application




                                                                                                           Building
Date of engagement        Name                                          BSA Certification license number
                                                                                                           classifi cation /s




QLEAVE NOTIFICATION AND PAYMENT (for completion by assessment manager or private certifier if applicable)
                                                                                        Date receipted

                                  QLeave Project          Amount paid                   form sighted by.   Name of officer who
Description of the work                                                     Date paid
                                  Number                  ($)                           assessment         sighted the form
                                                                                        manager




 The Sustainable PlanningAct 2009 (SPA)is administered by the Department of Infrastructure and Planning. This form and
 all other required application materials should be sent to your assessment manager and any referral agencies.



                 7                                                                       Application details-IDAS form 1
                                                                                           Version 1.0 18 December 2009