Development application part 1 of 2 MCU12 · MCU12/0012

Privacy-the information collected in this form will be used by the Department of Infrastructure and Planning (DIP) in
accordance with the processing and assessment of your application. Your personal details will not be disclosed for a purpose
outside of the IDAS process, except where required by legislation (including the Rightto /nformationAct2009) or as required
by Parliament. This information may be stored in a departmental database. The information collected will be retained as
required by the Public Records Act 2002.



OFFICE USE ONLY
 Date received                                           Reference numbers


NOTIFICATION OF ENGAGEMENT OF A PRIVATE CERTIFIER
 To                                       Council. I have been engaged as the private certifier for the building work referred
                                          to in this application


                                                                                                         Building
Date of engagement        Name                                       BSA Certification license number
                                                                                                         classification/s




QLEAVE NOTIFICATION AND PAYMENT (for completion by assessment manager or private certifier if applicable)
                                                                                       Date receipted
                                  QLeave Project       Amount paid                     form sighted by    Name of officer who
Description of the work                                                   Date paid
                                  Number               ($)                             assessment         sighted the form
                                                                                       manager




 The Sustainable P/anningAct2009(SPA) is administered by the Department of Infrastructure and Planning. This form and
 all other required application materials should be sent to your assessment manager and any referral agencies.


                                                                                           ;,!,   ,         IDASform i
                                                                                          Version j. o f8 Dei ember 2000