20200228 - Change Application Form (002) · 132001.210037.3

PART 8 – FOR OFFICE USE ONLY

Date                                         Reference number(s):
received:


QLeave notification and payment
Note: For completion by assessment manager if applicable
Description of the work
QLeave project number
Amount paid ($)
Date paid
Date receipted form sighted by assessment
manager
Name of officer who sighted the form




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