Form 5 · 51987.2900.1

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
Version 1.0—3 July 2017