Operational Works Application OPW26/0086 - DA Form 1, Standard drawing, xover drawing, Photo images - 125 Cooroy Belli Creek Rd, Cooroy

 25) Applicant declaration
 H By making this development application, I declare that all information in this development application is true and
     correct
 IjxlWhere an email address is provided in Part 1 of this form, I consent to receive future electronic communications
     from the assessment manager and any referral agency for the development 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.
Privacy - Personal information collected in this form will be used by the assessment manager and/or chosen
assessment manager, any relevant referral agency and/or building certifier (including any professional advisers
which may be engaged by those entities) while processing, assessing and deciding the development application.
All information relating to this development application may be available for inspection and purchase, and/or
published on the assessment manager’s and/or referral agency’s website.
Personal information will not be disclosed for a purpose unrelated to the Planning Act 2016, Planning
Regulation 2017 and the DA Rules except where:
• such disclosure is in accordance with the provisions about public access to documents contained in the Planning
     Act 2016 and the Planning Regulation 2017, and the access rules made under the Planning Act 2016 and
     Planning Regulation 2017; or
• required by other legislation (including the Right to Information Act 2009)', or
• otherwise required by law.
This information may be stored in relevant databases. The information collected will be retained as required by the
    Public Records Act 2002.

PART 9 - FOR COMPLETION OF THE ASSESSMENT MANAGER - FOR OFFICE
USE ONLY

 Date received:                                         Reference number(s):

 Notification of engagement of alternative assessment manager
 Prescribed assessment manager
 Name of chosen assessment manager
 Date chosen assessment manager engaged
 Contact number of chosen assessment manager
 Relevant licence number(s) of chosen assessment
 manager

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




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                                                                                                         DA Form 1 - Development application details
                                                                                                                       Version 1.6— 2 August 2024