PlanningActForm5-Changeapplicationform (1)

11) Information request under Part 3 of the DA Rules
 I agree to receive an information request if determined necessary for this change application
 I do not agree to accept an information request for this change application
Note: By not agreeing to accept an information request I, the applicant, acknowledge:
• that this change application will be assessed and decided based on the information provided when making this change application and the
    assessment manager and any referral agencies relevant to the change application are not obligated under the DA Rules to accept any
    additional information provided by the applicant for the change application unless agreed to by the relevant parties
• Part 3 of the DA Rules will still apply if the application is an application listed under section 11.3 of the DA Rules.
Further advice about information requests is contained in the DA Forms Guide: Forms 1 and 2.



12) Further details
 Part 7 of DA Form 1 – Development application details is completed as if the change application was a development
   application and is provided with this application.


PART 7 – CHECKLIST AND APPLICANT DECLARATION

13) Change application checklist

I have identified the:
• responsible entity in 4); and
• for a minor change, any affected entities; and                                                                       Yes X
• for an other change all relevant referral requirement(s) in 10)
Note: See the Planning Regulation 2017 for referral requirements

For an other change application, the relevant sections of DA Form 1 – Development                                      Yes
application details have been completed and is attached to this application                                            Not applicable X
For an other change application, where building work is associated with the change                                     Yes
application, the relevant sections of DA Form 2 – Building work details have been
completed and is attached to this application                                                                          Not applicable X

Supporting information addressing any applicable assessment benchmarks is attached to
this application
Note: This includes any templates provided under 23.6 and 23.7 of DA Form 1 – Development application details          Yes X
that are relevant as a result of the change application, a planning report and any technical reports required by the
relevant categorising instrument(s) (e.g. the local government planning scheme, State Planning Policy, State
Development Assessment Provisions). For further information, see DA Forms Guide: Planning report template.

Relevant plans of the development are attached to this development application
Note: Relevant plans are required to be submitted for all relevant aspects of this change application. For further     Yes X
information, see DA Forms Guide: Relevant plans.



14) Applicant declaration
 By making this change application, I declare that all information in this change application is true and correct.
 Where an email address is provided in Part 1 of this form, I consent to receive future electronic communications
   from the responsible entity and any relevant affected entity or referral agency for the change application where
   written information is required or permitted pursuant to sections 11 and 12 of the Electronic Transactions
   Act 2001.
Note: It is unlawful to intentionally provide false or misleading information.




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                                                                                                        Planning Act Form 5 - Change application form
                                                                                                                       Version 1.2 — 7 February 2020