DA Form 1 Application Details · MCU18/0015

  25) Applicant declaration
     By making this development application, I declare that all information in this development 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 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 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
  Date receipted form sighted by assessment manager
  Name of officer who sighted the form

The Planning Act 2016, the Planning Regulation 2017 and the DA Rules are administered by the Department of
Infrastructure, Local Government and Planning. This form and all other required development application materials should
be sent to the assessment manager.


                                                                                                                        Page 11
                                                                                      DA Form 1 – Development Application details
                                                                                                        Version 1.0—3 July 2017