Change application form

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CI Coordinates of premises by longitude and latitude

Longitude(s) Latitude(s) Datum Local Government Area(s) (if applicable)
‘| Fy wese4
| (0 GDA94
| OO Other: [a
[O Coordinates of premises by easting and northing
| Easting(s) Northing(s) | Zone Ref. | Datum Local Government Area(s) (if applicable)
| O54 CO wess4
O55 0 cpa
| (156 0 Other:

 

 

 

 

 

 

 

 

 

       

3.3) Additional premises

C Additional premises are relevant to the original development approval and the details of these premises have
been attached in a schedule to this application
LC Not required

 

 

PART 3 — RESPONSIBLE ENTITY DETAILS

4) Identify the responsible entity that will be assessing this change application
Note: see section 78(3) of the Planning Act 2016

 

 

PART 4 — CHANGE DETAILS

   
 
  

  

5) Provide details of the existing development approval subject to this change application

Approval type Reference number Date issued Assessment
manager/approval entity

[Development permit 2009 634 21.0% - 2004 <n 3h} ne
C Preliminary approval be, \ as

(J Development permit 139002..22.012S

(1 Preliminary approval

 

 

 

 

 

 

 

6) Type of change proposed

6.1) Provide a brief description of the changes proposed to the development approval (e.g. changing.a development
yee Ce ACM MA AA a ec Ae [Memeo aa ee eee

Enclose @rrortr
6.2) What type of change does this application propose?

[UMinor change application — proceed to Part 5
(CJ Other change application — proceed to Part 6

 

 

 

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PART 5 — MINOR CHANGE APPLICATION REQUIREMENTS

OEM Rech elm ur encureUl rel yolrec Ue

[WNo — proceed to Part 7

O Yes - list all affected entities below and proceed to Part 7

Note: section 80(1) of the Planning Act 2016 states that the person making the change application must give notice of the proposal and the
details of the change to each affected entity as identified in section 80(2) of the Planning Act 2016. a ES]

Affected entity Pre-request response provided? (where a pre- Date notice given (where no pre-

request response notice for the application has been request response provided)

given, a copy of the notice must accompany this change

application)

(No

(Yes - pre-request response is attached to
this change application

(No
( Yes — pre-request response is attached to
this change application

CONo

(1 Yes — pre-request response is attached to
this change application

 

 

 

 

 

 

 

 

 

PART 6 — OTHER CHANGE APPLICATION REQUIREMENTS

Note: To complete this part it will be necessary for you to complete parts of DA Form 1 — Development application details and in some instances parts
of DA Form 2 - Building work details, as mentioned below. These forms are available at https://planning.dsdmip.qid.gov.au.

8) Location details - Are there any additional premises included in this change application that were not part of the

 

original development approval?

[No
0 Yes

  
 

  
   
   
 
    
 
 
    

9) Development details

9.1) Is there any change to the type of development, approval type, or level of assessment in this change
application?

[No

(1 Yes — the completed Sections 1 and 2 of Part 3 (Development details) of DA Form 1 — Development application
details as these sections relate to the new or changed aspects of development are provided with this application.

FWA Yer M Meio] oie] COMMA building work?

(No
(Yes — the completed Part 5 (Building work details) of DA Form 2- Building work details as it relates to the
change application is provided with this application.

 
 

140) Referral details — Does the change application require referral for any referral requirements?

rral agency triggered by the change application as if the change application was the original

 

(J Yes — the completed Part 5 (Referral details) of DA Form 1 — Development application details as it relates to the
change application is provided with this application. Where referral is required for matters relating to building

work the Referral checklist for building work is also completed.

  

41) Information request under Part 3 of the DA Rules

(| agree to receive an information request if determined necessary for this change application
(| do not agree to accept an information request for this change application
Note: By not agreeing to accept an information request I, the applicant, acknowledge:

 

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Planning Act Form 5 - Change application torn

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that this change application will be assessed and decided based on the information provided when making this change application and the
assessment manager and any referral agencies relevant to the change application are not obligated under the DA Rules to accept any
additional information provided by the applicant for the change application unless agreed to by the relevant parties

Part 3 of the DA Rules will 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: Forms 1 and 2.

CO Part 7 of DA Form 1— Development application details is completed as if the change application was a
development application and is provided with this application.

PART 7 — CHECKLIST AND APPLICANT DECLARATION

 

13) Change application checklist
| have identified the:

* — responsible entity in 4); and
¢ — for a minor change, any affected entities; and [Wrés

efor an other change all relevant referral requirement(s) in 10)
Note: See the Planning Regulation 2017 for referral requirements

 

 

For an other change application, the relevant sections of DA Form 1 —- Development 0 Yes
application details have been completed and is attached to this application (fot applicable
For an other change application, where building work is associated with the change Yes
application, the relevant sections of DA Form 2 — Building work details have been licabl
completed and is attached to this application [UAM6t applicable

 

Supporting information addressing any applicable assessment benchmarks is attached to

this application

Note: This includes any templates provided under 23.6 and 23.7 of DA Form 1 — Development application details Yves
that are relevant as a result of the change application, a planning report and any technical reports required by the

relevant categorising instrument(s) (e.g. the local government planning scheme, 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 all relevant aspects of this change application. For further yj y es
information, see DA Forms Guide: Relevant plans.

 

 

 

14) Applicant declaration

 

making this change application, | declare that all information in this change application is true and correct.
Where an email address is provided in Part 1 of this form, | consent to receive future electronic communications
from the responsible entity and any relevant affected entity or referral agency for the change 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 responsible entity and/or chosen

assessment manager, any relevant affected entity or referral agency and/or building certifier (including any

professional advisers which may be engaged by those entities) while processing, assessing and deciding the
change application.

All information relating to this change 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.

 

 

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PART 8 — FOR COMPLETION OF THE ASSESSMENT MANAGER - FOR OFFICE
USE ONLY

Date received: eee | Reference number(s): [ Al

 

 

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

 

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