08/1041 - Op Works - Landscaping, Drainage, Stormwater & Earthworks [As Published] · 142008.1041

INTEGRATED PLANNING ACT 1997 Part A, Version 3.1, 3 March 2008

2. _ Identify if any of the following apply to the premises by completing Tables D, E, or F. (Note: in most instances, the premises will not involve any of the
following characteristics, however some applications may involve one or more of these characteristics - complete only if applicable)

Table D Complete if the premises are adjacent to or associated with a water body, watercourse or aquifer (e.g. river, creek fake, cana)
Name of water body, watercourse or aquifer (if known}
1 N/a -

Table E Complete if the premises are on Strategic Port Land under the Transport Infrastructure Act 1994
,_Lgton plan description for strategic port land Port authority for the lot

. | N/a

Table F Complete if the premises are in tidal water

 

 

 

 

 

 

 

 

Name of local government for the tidal area (/f appicabte) Name of port authority for the tidaf area (if applicable)

1. N/A, -

3. Indicate the total area of the premises on which the development is proposed: (Note: The total area may include land both above and below water)
Total area of premises (land on which tbe development is proposed)

T}Z)O|}- & 5 ne LD hectares ;~appiicabte und}

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Existing use of the premises
4. Current use/s of the premises: (e.g. vacant land, house, townhouses, apartment building, shop, service station, school, sugar cane farming etc.)

5, Are there any existing planet on the premises? (e.g. for vehicular access, electricity, overland flow, water etc.)
O No Yes - Ensure ine type location and dimensions of each easement are inched in plans, submited veth the application

 

 

 

 

Proposal details
6. Brief description of the proposal: (e.g. 6 unit apartment building, 30 lot residential subdivision, a bore, aquaculture etc.)

“DUPLEX “DWELLING

7. Does the proposal insu building work or operational work (including any services) on the premises?

oO No Yes ~ Ensure the nature, location and dimensions of ine proposed works are included in plans. submitted with ihe application

 

 

 

 

Resource entitlement (# appticable) - futher information is provided in tha advice section at the end of the farm
8. Does the application involve taking or interfering with a State resource and therefore require a resource entitlement? (e.g. the application
we Stete land (leased and freehold), declared Fish Habitat areas, taking quarry material, taking or interfering with water under the Water Act 2000. atc.)
No - Goto G9 oO Yes - Complete Table G - provide dotails for each evidence required on a separate row, if applicable. Evidence of resource alfocation or
anfitement musi be submitted with the aoplicetion. You do not need tc answer Q9 - go to the next section
Nature of State-owned resource
Table G [Nature of evidence required

Allocation/entitlement
reference number

 

 

 

a a . State Government Date of | Date of
Name of authorising officer Position of authorising officer Department issue | expiry

 

 

 

 

 

 

 

 

 

 

Owner’s consent (# applicable) — Axther information is provided in the advice section at the end of the forza |

9. Complete Table H for applications involving a material change of use; reconfiguration of a lot; work on land below high-water mark and not
within a canal as defined under the Coastal Protection and Management Act 1995, or work on rail corridor land defined under the
Transport infrastructure Act 1994 - provide details for each owner on a separate row, oF on an attachment io this form sf appicable

 

Date consent
was obtained

Table H Premises Owner's namels Details of the premises owned

ie *
and postal address (street address or fot on plan description} Owners signature

 

 

 

 

 

 

 

 

 

* owner's signature cannot be provided on the form if you intend to submit the application electronicaily. Owner's consent must be provided to the assessment manager on an
attachment containing appropriate written documentation of the owner's consent. If the owner is a company, $127 of the Corporations Act 2001 (Cweatth) details how a
company may sign as owner. Templates for the provision of owner's consent are available on the IPA website .

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