Pre Request Response Application form · 132006.268.03

4. Location of the premises
Unit No.                      Street No 314                Street Cooroy Mountain Road,
Suburb Cooroy                                                          State QLD                          Postcode
Lot no.                       Plan type & plan no.
Lot 2                          SP143409




5. Declaration of applicant
I/We, the applicant, declare that the above information is correct in all respects, at the time of lodgement of this
application with Council. Should any of the details given in relation to this application be changed in the future, the
applicant shall advise Council in writing prior to any such change being implemented.
Signature                                                                                            Date 12/10/2017


OFFICE USE ONLY
Application no.      Amount paid          Date paid            Receipt no.          Initial              Date stamp


Receiving Officer




Payment options

In person     9 Pelican Street, Tewantin: 8.30 am to 4.30 pm Monday to Friday (excludes public holidays).
By mail       Cheque or money order to be made payable to Noosa Council.
               Cheque                        Money order                   Mastercard                   Visa
              Card number                                                   Expiry date                   Amount $
              Name on card                                                  Signature of cardholder
              Phone                                                         Is a receipt required?          Yes          No
All payments made by credit card will incur a 0.50% surcharge (exempt of GST) to reflect the cost of fees charged for credit card
transactions.



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