Operational Works Application OPW18/0181 - 75 Cudgerie Dr, Black Mountain

Be eg A ake ee cree

Department of Infrastructure, Local Government and Planni

 

PART 9 — FOR OFFICE USE ONLY

Date received: [gece ot ae. | 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

QLeave notification and payment
Note: For completion by assessment manager if applicable

Description of the work

 

 

 

QLeave project number

Amount paid ($)

Date paid

Date receipted form sighted by assessment manager
Name of officer who sighted the form

 

 

 

 

 

 

 

 

The Planning Act 2016, the Planning Regulation 2017 and the DA Rules are administered by the Department of
Infrastructure, Local Government and Planning. This form and all other required development application materials should
be sent to the assessment manager.

Page 11
DA Form 1 - Development Application details
Version 1.0—3 July 2017