DA Form 1

Page 2

 

Street address AND lot on plan (aii /ots must be listed), or

Street address AND lot on plan for an adjoining or adjacent property of the premises (appropriate for development in water but
adjoining or adjacent to land e.g. jetty, pontoon. All lots must be listed).

 

 

 

 

 

a) UnitNo. Street No. Street Name and Type Suburb :
4a = Blacx Mowpain foacl ,  COOg oy
Postcode Lot No. Plan Type and Number (e.g. RP. SP) Local Government Area(s)
156 F “UW E> Eso
b) UnitNo. Street No. Street Name and Type Suburb
Postcode Lot No. Plan Type and Number (e.g. RP, SP) Local Government Area(s)

Coordinates of premises by longitude and latitude

 

 

 

 

 

 

 

 

Longitude(s) Latitude(s) Datum Local Government Area(s) (if applicable)
IWGS84
IGDA94
Other:
Coordinates of premises by easting and northing
Easting(s) Northing(s) [Zone Ref. Datum Local Government Area(s) (if applicable)
54 \WGS84
5S IGDA94
56
Other:

 

 

 

 

‘Additional premises are relevant to this development application and the details of these premises have been attached
in a schedule to this development application

Not required

 

 

In or adjacent to a water body or watercourse or in or above an aquifer

 

Name of water body, watercourse or aquifer:

 

On strategic port land under the Transport Infrastructure Act 1994

 

Lot on plan description of strategic port land:

 

Name of port authority for the lot:

 

 

Ina tidal area

 

 

 

Nama af lanal anvarnmant far the tidal araa if vnnlinvhinl* |

  

Queensland
’ Government

 

 

EN

Listed on the Environmental Management Register (EMR) under the Environmental Protection Act 199
EMR site identification:

 

 

 

Listed on the Contaminated Land Register (CLR) under the Environmental Protection Act 1994
CLR site identification: |

 

 

 

 

Yes — All easement locations, types and dimensions are included in plans submitted with this development application

 

 

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PART 3 — DEVELOPMENT DETAILS

Section 1 — Aspects of development

a) What is the type of development? (tiok only one box)
Material change of use Reconfiguring alot ¢ Operational work Building work
b) What is the approval type? (tick only one box)

< Development permit Preliminary approval _ Preliminary approval that includes a variation approval
c) What is the level of assessment?

YsCode assessment Impact assessment (requires public notification)

d) Provide a brief description of the proposal (e.g. 6 unit apartment building defined as multi-unit dwelling, reconfiguration of 1 lot into 3
lots):
Sony De@weudn,
e) Relevant plans

Note: Relevant plans are required to be submitted for all aspects of this development application. For further information, see DA Forms quide:
Relevant plans,

Relevant plans of the proposed development are attached to the development application

a) What is the type of development? (tick only one box)

Material change of use Reconfiguring a lot Operational work Building work

b) What is the approval type? (tick only one box)

Development permit Preliminary approval _—_ Preliminary approval that includes a variation approval
c) What is the level of assessment?

Code assessment Impact assessment (requires public notification)

d) Provide a brief description of the proposal (e.g. 6 unit apartment building defined as multi-unit dwelling, reconfiguration of 1 Jot into 3
lots):

e) Relevant plans
Note: Relevant pians are required to be submitted for all aspects of this development application. For further information, see DA Eorms Guide:
Relevant plans.

Relevant plans of the proposed development are attached to the development application

Additional aspects of development are relevant to this development application and the details for these aspects that
would be required under Part 3 Section 1 of this form have been attached to this development application
Not required

Section 2 — Further development details

Material change of us¥es — complete division 1 if assessable against a local planning instrument
Reconfiguring a lot Yes -— complete division 2
“Koperational work Yes — complete division 3

Building work Yes — complete DA Form 2 - Building work details

Division 1 — Material change of use

Note: This division is only required to be completed if any part of the development application involves a material change of use assessable against a
local planning instrument.

Provide a general description of the Provide the planning scheme definition © Number of dwelling Gross floor
proposed use (include each definition in a new row) units (if applicable) area (m’)
(if applicable)

 

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No

Division 2 — Reconfiguring a lot

Note: This division is ai ee tobe ee if. i a: of the ie ae involves sz a iot.

Subdivision (complete 10)) Dividing land into parts by agreement (complete 11))

Boundary realignment (complete 12)) Creating or changing an easement giving access to a lot froma
constructed road (complete 13))

Intended use of lots created Residential Commerciallndustriather, please specify:

Number of lots created

Yes — provide additional details below
No

How many stages will the works include?

What stage(s) will this development application apply
to?

Intended use of parts created Residential Commercial Industrial Other, please specify:
Number of parts created

Current lot Proposed lot
Lot on plan description Area (m?) — Lot on plan description Area (m?)

Existing or Width (m) Length (m)Purpose of the easement? (e.g. pedestrian Identify the land/lot(s)
proposed? access) benefitted by the easement

Division 3 - Operational work

Note: This division is a ae tobe BT if. Be % of the as ae involves we work,

Road work Stormwater Water infrastructure
Drainage work Earthworks Sewage infrastructure
Landscaping Signage Clearing vegetation

XY Other — please specify: ¢ Lo SSO ee

 

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Yes — specify number of new lots:

sQNo

=

PART 4 —- ASSESSMENT MANAGER DETAILS

|

Noos4 Cowlcil.

Yes ~ a copy of the decision notice is attached to this development application

The local government is taken to have agreed to the superseded planning scheme request — relevant documents
attached

Sa No

PART 5 — REFERRAL DETAILS

Nn No, there are no referral requirements relevant to any development aspects identified in this development application
~ proceed to Part 6

 

Matters requiring referral to the Chief Executive of the Planning Act 2016:

 

Clearing native vegetation

Contaminated land (unexploded ordnance)

Environmentally relevant activities (ERA) (only if the ERA has not been devolved to a local government)

Fisheries — aquaculture

Fisheries — declared fish habitat area

Fisheries — marine plants

Fisheries — waterway barrier works

Hazardous chemical facilities

Heritage places — Queensland heritage place (on or near a Queensland heritage place)

Infrastructure-related referrals — designated premises

Infrastructure-related referrals — state transport infrastructure

Infrastructure-related referrals — State transport corridor and future State transport corridor

Infrastructure-related referrals — State-controlled transport tunnels and future state-controlled transport tunnels

Infrastructure-related referrals — near a state-controlled road intersection

Koala habitat in SEQ region — interfering with koala habitat in koala habitat areas outside koala priority areas

Koala habitat in SEQ region ~ key resource areas

Ports — Brisbane core port land — near a State transport corridor or future State transport corridor

Ports — Brisbane core port land — environmentally relevant activity (ERA)

Ports — Brisbane core port land — tidal works or work in a coastal management district

Ports — Brisbane core port land — hazardous chemical facility

Ports — Brisbane core port land — taking or interfering with water

Ports — Brisbane core port land — referable dams

Ports — Brisbane core port land — fisheries

Ports — Land within Port of Brisbane’s port limits (below high-water mark)

SEQ development area

SEQ regional landscape and rural production area or SEQ rural living area — tourist activity or sport and recreation
activity

ISEQ regional landscape and rural production area or SEQ rural living area - community activity

SEQ regional landscape and rural production area or SEQ rural living area ~ indoor recreation

SEQ regional landscape and rural production area or SEQ rural living area - urban activity

SEQ regional landscape and rural production area or SEQ rural living area ~- combined use

SEQ northern inter-urban break — tourist activity or sport and recreation activity

ISEQ northern inter-urban break — community activity

SEQ northern inter-urban break — indoor recreation

SEQ northern inter-urban break — urban activity

SEQ northern inter-urban break — combined use

Tidal works or works in a coastal management district

Reconfiguring a lot in a coastal management district or for a canal

 

 

 

 

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Erosion prone area in a coastal management district

Urban design

\Water-related development — taking or interfering with water

Water-related development - removing quarry material (from a watercourse or lake)
Water-related development - referable dams

Water-related development -levees (category 3 levees only)

Wetland protection area

 

Matters requiring referral to the local government:

 

Airport land
Environmentally relevant activities (ERA) (only if the ERA has been devolved to local government)
Heritage places — Local heritage places

 

Matters requiring referral to the Chief Executive of the distribution entity or transmission entity:
Infrastructure-related referrals — Electricity infrastructure

 

Matters requiring referral to:
* The Chief Executive of the holder of the licence, if not an individual

* The holder of the licence, if the holder of the licence is an individual
Infrastructure-related referrals — Oil and gas infrastructure

 

Matters requiring referral to the Brisbane City Council:
Ports — Brisbane core port land

 

Matters requiring referral to the Minister responsible for administering the Transport Infrastructure Act 1994:
Ports — Brisbane core port land (where inconsistent with the Brisbane port LUP for transport reasons)
Ports — Strategic port land

 

Matters requiring referral to the relevant port operator, if applicant is not port operator:
Ports — Land within Port of Brisbane’s port limits (below high-water mark)

 

Matters requiring referral to the Chief Executive of the relevant port authority:
Ports — Land within limits of another port (below high-water mark)

 

Matters requiring referral to the Gold Coast Waterways Authority:
Tidal works or work in a coastal management district (in Gold Coast waters)

 

 

 

Matters requiring referral to the Queensland Fire and Emergency Service:
Tidal works or work in a coastal management district (involving a marina (more than six vessel berths)

Yes — referral response(s) received and listed below are attached to this development application
No

Referral requirement Referral agency Date of referral response

 

 

 

 

 

 

 

 

Identify and describe any changes made to the proposed development application that was the subject of the referral
response and this development application, or include details in a schedule to this development application (if applicable).

PART 6 —- INFORMATION REQUEST

¥ | agree to receive an information request if determined necessary for this development application
| do not agree to accept an information request for this development application
Note: By not agreeing to accept an information request |, the applicant, acknowledge:
® that this development application will be assessed and decided based on the information provided when making this development application and

the assessment manager and any referral agencies relevant to the development application are not obligated under the DA Rules to accept
any additional information provided by the applicant for the development application unless agreed to by the relevant parties

*® Part 3 of the DA Rules willl still apply if the application is an application listed under section 11.3 of the DA Rules.
Further advice about information requests is contained in the DA Forms Guide.

PART 7 — FURTHER DETAILS

 

 

Page 7

List of approval/development Reference number Date Assessment manager
application references

Approval Mua foo! d{7/>)

Development application

 

Approval
Development application

 

Yes — a copy of the receipted QLeave form is attached to this development application
No — |, the applicant will provide evidence that the portable long service leave levy has been paid before the
assessment manager decides the development application. | acknowledge that the assessment manager may give
a development approval only if | provide evidence that the portable long service leave levy has been paid
jot applicable (e.g. building and construction work is less than $150,000 excluding GST)

Amount paid Date paid (dd/mm/yy) QLeave levy number (A, B or E)

 

 
   

Yes — show cause or enforcement notice is attached

FR No

 

Yes — the required attachment (form ESR/2015/1791) for an application for an environmental authority accompanies
this development application, and details are provided in the table below
= No
Note: Application for an environmental authority can be found by searching “ESR/2015/1791” as a search term at www.gid.gov.au. An ERA requires
an environmental authority to operate. See www.business.gid.gov.au for further information.

Proposed ERA number: Proposed ERA threshold:

Proposed ERA name:

 

 

Multiple ERAs are applicable to this development application and the details have been attached in a schedule to this
development application.

    

Yes — Form 69: Notification of a facility exceeding 10% of schedule 15 threshold is attached to this development
application

No

Note: See www business. gid. gov.au for further information about hazardous chemical notifications.

 

Yes — this development application includes written confirmation from the chief executive of the Vegetation
Management Act 1999 (s22A determination)

ino

  

Note: 7. Where a development application for operational work or material change of use requires a s22A determination and this is not
included, the development application is prohibited development.
2. See https: Awww.gid.gov.au/environment/land/vegetation/applying for further information on how to obtain a s22A determination.

Yes — | acknowledge that an environmental offset must be provided for any prescribed activity assessed as having a
significant residual impact on a prescribed environmental matter
No

Note: The environmental offset section of the Queensland Government's website can be accessed at www.qld.gov.au for further information on
environmental offsets.

 

Page 8

Yes — the development application involves premises in the koala habitat area in the koala priority area
Yes — the development application involves premises in the koala habitat area outside the koala priority area

No

Note: if a koala habitat area determination has been obtained for this premises and is current over the /and, it should be provided as part of this
development application. See koala habitat area guidance materials at www.des.qid.gov.au for further information.

Water resources

23.6) Does this development application involve taking or interfering with underground water through an artesian

or subartesian bore, taking or interfering with water in a watercourse, lake or spring, or taking overland flow
water under the Water Act 2000?

 

Yes ~ the relevant template is completed and attached to this development application and | acknowledge that a
relevant authorisation or licence under the Water Act 2000 may be required prior to commencing development

.
1
Eco Contact the Department of Natural Resources, Mines and Energy at www.dnrme.gid.goy.au for further information.
DA templates are available from https://planning.dsdmip.gid.gov.auy. If the development application involves:
* Taking or interfering with underground water through an artesian or subartesian bore: complete DA Form 1 Template 1

 

 

* Taking or interfering with water in a watercourse, lake or spring: complete DA Form1 Template 2
* Taking overland flow water: complete DA Form 1 Template 3.

Waterway barrier works

WOM Olea nel) ole Me MECN ENA Lim el cig

 

Yes — the relevant template is completed and attached to this development application
io

DA templates are available from bttos://planning.dsdmip.aid.gov.au/ For a development application involving waterway barrier works, complete DA
Form 1 Template 4.

  
   

Yes — an associated resource allocation authority is attached to this development application, if required under the
Fisheries Act 1994
‘€ No
Note: See guidance materials at www. daf.gid.gov.au for further information.

Yes ~ | acknowledge that a quarry material allocation notice must be obtained prior to commencing development

No
Note: Contact the Department of Natural Resources, Mines and Energy at www.dnrme.gid.gov.au and www. business. gid.gov.au for further
information.

 

Yes — | acknowledge that a quarry material allocation notice must be obtained prior to commencing development
No
Note: Contact the Department of Environment and Science at www.des.g/d.9ov.au for further information.

   

Yes ~ the ‘Notice Accepting a Failure Impact Assessment’ from the chief executive administering the Water Supply Act
is attached to this development application

No
x Note: See guidance materials at www.dnrme.qid.gov.au for further information.

Yes — the following is included with this development application:

Evidence the proposal meets the code for assessable development that is prescribed tidal work (only required if
application involves prescribed tidal work)

A certificate of title
so No
Note: See guidance materials at www.des.g/d.goy.au for further information.

Yes — details of the heritage place are provided in the table below

No
Note: See guidance materials at www des.gid.goy.au for information requirements regarding development of Queensland heritage places.

ro] T

Page 9

Name of the heritage place:

 

Yes — this development application demonstrates how the proposal meets the code for a development application for a
brothel under Schedule 3 of the Prostitution Regulation 2014

pxNo

Decision under section 62 of the Transport Infrastructure Act 1994

  

23.15)

Yes — this application will be taken to be an application for a decision under section 62 of the Transport Infrastructure
Act 1994 (subject to the conditions in section 75 of the Transport Infrastructure Act 1994 being satisfied)

“YSNo

Yes — Schedule 12A is applicable to the development application and the assessment benchmarks contained in
schedule 12A have been considered

~No
Note: See guidance materials at www planning.dsdmip. gid. goy.au for further information.

PART 8 — CHECKLIST AND APPLICANT DECLARATION

| have identified the assessment manager in question 15 and all relevant referral
requirement(s) in question 17 Yes ~
Note: See the Planning Regulation 2017 for referral requirements

 

If building work is associated with the proposed development, Parts 4to6 of DAForm2- {Yes
Building work details have been completed and attached to this development application Not applicable we

 

Supporting information addressing any applicable assessment benchmarks is with the

development application
Note: This is a mandatory requirement and includes any relevant templates under question 23, a planning report Yes ZZ -

and any technical reports required by the relevant categorising instruments (e.g. local government planning
schemes, State Planning Policy, State Development Assessment Provisions). For further information, see DA Forms}
Guide: Planning Report Template.

Relevant plans of the development are attached to this development application

 

Note: Relevant plans are required to be submitted for al! aspects of this development application. For further Yes —
information, see DA Forms Guide: Relevant plans.

The portable long service leave levy for QLeave has been paid, or will be paid before a Yes

development permit is issued (see 27) Not applicable Yv.

 

 

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

ere 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: /t 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 COMPLETION OF THE ASSESSMENT MANAGER - FOR OFFICE

Page 10

USE ONLY

|

Date receivedReference number(s):

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

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