DA Form 5

11) Information request under Part 3 of the DA Rules
 ☒    I agree to receive an information request if determined necessary for this change application
 ☐    I 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:
   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.


12) Further details
 ☒    Part 7 of DA Form 1 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
I have identified the:                                                                                    ☒      Yes
 responsible entity in 4); and
 for a minor change, any affected entities; and
 for an ‘other’ change all relevant referral requirement(s) in 10)
Note: See the Planning Regulation 2017 for referral requirements

                                                                                                          ☐      Yes
For an ‘other’ change application, the relevant sections of DA Form 1 - Development
application details have been completed and is attached to this application                               ☒      Not 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 completed
and is attached to this application                                                                       ☒      Not applicable
Supporting information addressing any applicable assessment benchmarks is attached to                     ☒      Yes
this application
Note: This includes any templates provided under 23.6 and 23.7 of DA Form 1 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                            ☒      Yes
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.


14) Applicant declaration
 ☒    By making this change application, I declare that all information in this change application is true and correct.
 ☒    Where an email address is provided in Part 1 of this form, I 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:
     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
     required by other legislation (including the Right to Information Act 2009); or
     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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                                                                                      Planning Act Form 5 - Change application form
                                                                                                     Version 1.2 — 7 February 2020