Costelloe - DA Form 1

25) Applicant declaration

By making this development application, | declare that all information in this development application is true and
correct

wi Where an email address is provided in Part 1 of this form, | 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:

e 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

e required by other legislation (including the Right to Information Act 2009); or

e 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: [ti‘éCézd 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

Qkeave 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

 

 

 

 

° Page 12
DA Form 1 — Development application details
Version 1.6— 2 August 2024