2. 220148 - DA Form 5 · 132006.2554.01

 This information may be stored in relevant databases. The information collected will be retained as required by the
 Public Records Act 2002.

PART 8 – FOR COMPLETION OF THE ASSESSMENT MANAGER – FOR OFFICE
USE ONLY

 Date received:                                   Reference number(s):

 QLeave notification and payment
 Note: For completion by assessment manager if applicable
 Description of the work                                             Additions & Alterations – New Bathroom, internal
                                                                     reconfiguration + Inground Swimming Pool and Pool
                                                                     Barrier
 QLeave project number                                               S295937
 Amount paid ($)              $10,827.00                             Date paid (dd/mm/yy)          24/02/2022
 Date receipted form sighted by assessment manager                   04/03/2022
 Name of officer who sighted the form                                Richard Jones




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