Form 5 · 51987.2900.1

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Department of Infrastructure, Local Government and Planning

 

5) Type of change proposed

5.1) Provide a brief description of the changes proposed to the development approval (e.g. changing a development approval for a
5 unit apartment building to provide for a 6 unit apartment building):

 

yp, IFEK
Minor CHALE TO DEVEL EPMEWT A PPRovVAK (7 Pe tell.) Fok
ADDITIONS TO Acc Orvis DAT OP eb wot

 

5.2) What type of change does this application propose?
Minor change application — proceed to Part 4
(J Other change application — proceed to Part 5

 

PART 4 — MINOR CHANGE APPLICATION REQUIREMENTS

6) Are there any affected entities for this change application
[4 No — proceed to Part 6

C1 Yes - list all affected entities below and proceed to Part 6
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.

Affected entity Pre-request response provided? (where a pre- | Date notice given (where no pre-
request response notice for the application has | request response provided)

been given, a copy of the notice must
accompany this change application)

LI No

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

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

LI No
C1 Yes — pre-request response is attached to
this change application

 

 

 

 

 

 

 

 

L

 

 

PART 5 — OTHER CHANGE APPLICATION REQUIREMENTS

Note: to complete this part it will be necessary for you to complete parts of DA Form 1 and in some instances parts of DA Form 2, as
mentioned below. These forms are available at www.dilgp.gld.gov.au.

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

development approval?

LI No
LJ Yes — complete Part 2 (Location details) of DA Form 1 as it relates to the additional premises is completed and
provided with this application.

 

      
 

8) Development details
8.1) Are there any new or changed development aspects included in this change application that are not part of the
original development approval?

L] No — proceed to 9)
LJ Yes — the completed Sections 1 and 2 of Part 3 (Development details) of DA Form 1 as these sections relate to the
new or changed aspects of development are provided with this application.

     
 
   
 

8.2) Does the change application involve building work?

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

  

 

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Planning Act Form 5 - Change application form
Version 1.0—3 July 2017

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Department of Infrastructure, Local Government and Planning

 

9) Referral details - Do any aspects of the change application require referral for any referral requirements?

Note: The application must be referred to each referral agency triggered by the change application as if the change application was the original
development application including the proposed change.

L1No

LJ Yes — the completed Sections 1 and 2 of Part 5 (Referral details) of DA Form 1 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.

 

 

10) Information request under Part 3 of the DA Rules

 

C] | agree to receive an information request if determined necessary for this change application
(11 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:

e 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

e 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.

 

11) Further details

L] Part 7 of DA Form 1 is completed as if the change application was a development application and is provided with this
application.

 

 

 

 

PART 6 — CHECKLIST AND APPLICANT DECLARATION

12) change application checklist

| have identified the:
e responsible entity in 3); and
e for a minor change, any affected entities; and ae
e foran ‘other’ change all relevant referral requirement(s) in 9)

Note: See the Planning Regulation 2017 for referral requirements

 

 

For an ‘other’ change application, the relevant sections of DA Form 1 — Development C] Yes
No

 

details have been completed and is attached to this application t applicable
For an ‘other’ change application, where building work is associated with the change C1 Yes
application, the relevant sections of Form 2 — Building work details have been No fopleeble

completed and is attached to this application

 

Supporting information addressing any applicable assessment benchmarks is attached

to this application

Note: This includes any templates provided under 23.6) of DA Form 1 that are relevant as a Ve
result of the change application, a planning report and any technical reports required by the Ye
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
uYes

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

 

 

24) Applicant declaration

 

By-making this change application, | declare that all information in this change application is true and correct.

fuWhere 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.

 

 

 

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Planning Act Form 5 - Change application form
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Department of Infrastructure, Local Government and Planning

 

 

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 2076, 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 7 — FOR OFFICE USE ONLY

Date received: (oe | Reference number(s): [

 

 

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 change application materials should be
sent to the responsible entity.

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Planning Act Form 5 - Change application form
Version 1.0—3 July 2017