OPW13/0007 Application for permit to damage vegetation 3 Black Mountain Rd Black Mountain

12. Is the payment of a portable long service leave levy applicable to this application? (Refer to notes at the end
of this form for more information.)


IQ( No-go      to question 14          DYes

13. Has the portable long service leave levy been paid? (Refer to notes at the end of this form for more
information.)


D     No

D     Yes-<:omplete Table N and submit with this application the yellow local government/private certifier’s copy of the
      receipted QLeave form

Table N

Amount paid                Date paid       QLeave project number (6digit number starting with A, B, E, L or P)

                           (dd/mm/yy)




14. Has the local government agreed to apply a superseded planning scheme to this application l.Inder section
96 of the Sustainable Planning Act 2009?


g’    No


D     Yes-please provide details below


Name of local government                          Date of written notice given     Reference number of written notice given
                                                  by local government              by local government (if applicable)
                                                  (dd/mm/yy)




15. List below all of the forms and supporting information that accompany this application (Include alllDAS
forms, checklists, mandatory supporting information etc. that will be submitted as part of this application. Note: this
question does not apply for applications made online using Smart eDA.)

Description of attachment or title of attachment                                             Method of lodgement to
                                                                                             assessment manager
 /’                    ,



(I A           b   )
’--                I




           x                                     .
                                                     ~

16.Applicant’s declaration


    By making this application, I declare that all in~ rmation in t is Pplica!ion is true and correct (Note:it is unlawful to
provide false or misleading information.)




6                                                                                                 /DAS form 1-Application details
                                                                                                    Version 2.0 17 December 2012