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DA Form 1 - Development application details
Approved form (version 1.3 effective 28 September 2020) made under section 282 of the Planning Act 2016.
This form must be used to make a development application involving code assessment or impact assessment,
except when applying for development involving only building work.
For a development application involving building work only, use DA Form 2 - Building work details.
For a development application involving building work associated with any other type of assessable development
(i.e. material change of use, operational work or reconfiguring a lot), use this form (DA Form 1) and parts 4 to 6 of
DA Form 2 - Building work details.
Unless stated otherwise, all parts of this form must be completed in AjII and all required supporting information must
accompany the development application.
One or more additional pages may be attached as a schedule to tnis development application if there is insufficient
space on the form to include all the necessary information.
This form and any other form relevant to the development application must be used to make a development
application relating to strategic port land and Brisbane core port land under the Transport Infrastructure Act 1994,
and airport land under the Airport Assets (Restructuring and Disposal) Act 2008. For the purpose of assessing a
development application relating to strategic port land and Brisbane core port land, any reference to a planning
scheme is taken to mean a land use plan for the strategic port land, Brisbane port land use plan for Brisbane core
port land, or a land use plan for airport lanu.
Note: All terms used in this form have the meaning given under the Planning Act 2016, the Planning Regulation 2017, or the Development
Assessment Rules (DA Rules). ‘' ■
PART 1 - APPLICANT DETAILS
Applicant name(s) (individual or company full name) David E Hughes & Jennifer A Crowcombe
Contact name (only applicable for comparias)
Postal address (P.O. Box or street address) 121 Tinbeerwah Rd 10
Suburb Tinbeer.rah
State Old
Postcode 4563 r j FEB F
Country Australia ArNoosaWcilA
. Noosa
Contact number 0406 089 541 (Jennifer) \ CTGounterZ/V/
Email address (non-mandatory) [email protected]
Mobile number (non-mandatory) As above
Fax number (non-mandatory)
Applicant’s reference number(s) (if applicable)
2) Owner’s consent
---- ------------------------------------------------ :------- 7----- -- '' ------------- Ji------
2 1) Is written consent of the owner required for this developmefi^application?^ •
□ Yes - the written consent of the owner(s) is attached to this development application
□ No - proceed to 3) y
■to
7 %
He
y1
'•i-F
/Box: R: PteS™ Queensland
I Government
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Page 2
i"'
PART 2 - LOCATION DETAILS
3) Location Of the premises (complete 3.1) or 3.9). and 3.3) as applicate)
Note: Provide details below and attach a-site plan for any or all Premises paiftMhe development application. Pof further information, see DA
Forms Guide: Relevant plans.
3 1) Street address and lot on plan - '
Street address AND lot on plan (ail lots must be listed), or
Street address AND lot on plan for an adjoining or adjacent property of the premises (appropriate for development in
water but adjoining or adjacent to land e g. jetty, pontoon. , JI lots must be listed).
Unit No. Street No. Street Name and Type Suburb
11 UoA H ______
a)
Postcode Lot No. Plan Type and Number (e.g. RF SP) Local Government Area(s)
Unit No.
r Ai^/F •
Street No. Street h'^me and Type Suburb
___ g___ ___________________ _ *
b)
Postcode Lot No. Plan Type and Number (e.g.-RP, SP) Local Government Area(s)
3.2) Coordinates Of premise^ (appropj^ate for developmental remote 'Seas, ^ove'i
[part otpr lot or in water not adjoining or adjacent to land
e g. channel dredging in Moreton Bay)' <• '♦ *' .'L
Note: Piftpe each set;of coordinates in a separate, row * ®
| 0 Coordinates of premises by longitude and latitude !
________________________________ )
Longitude(s) Latitude(s) Datum Local Government Area(s) (if applicable)
WGS8.
GDA94
\ \ □ Other:
I Coordinates of premises by easting and northing
Easting(s) Northing(s) ! Zone Ref. Datum Local Government Area(s) (if applicable)
54 S □.WGS84
55 ! ^D.’ 94
______ ________________________ | 56 Omer: f
Additional premises are relevant to this development apolication and the details of these premises have been
attached in a schedule to this development applicauon
0 Not required ' . >
4) Identify any of the following that'apply to the premises andTrqvijfe any relevant details
In or adjacent to a water body or watercourse or in or above an aquifer
Name of water body, watercourse or aquifer:
On strategic port land under the Transport Infrastructure Act 1994
Lot on plan description of strategic port land:
Name of port authority for the lot: . i
In a tidal area
Name of local government for the tidal area (if applicable). '!
Name of port authority for tidal area (if appiicab'e):
On airport land under the Airport Assets .(Restructuring and Disposal) Act 2008
Name of airport:
*
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DA Form 1 - Development application details
Version 1.3— 28 September 202.0
Page 3
0 Listed on the Environmental Management Register (EMR) under the Environmental Protection Act 1994
EMR site identification:
------------------------------ - ------------------------ - -------------------- —.. '--------------- _______ L_______ _________________________________________________
0 Listed on the Contaminated Land Reg...ter (CLR) uno^r tue Environmental Protection Act 1994
CLR site identification: I
5) Are there any existing easements over thej>remises?
Note: Easement uses vary throughout Queensland and,are to be icHSntified co^ctlv^afKieccurateiy For further information oh easements and
how they may affect the proposed development,. seerDA Forms (Guide * ■- ■ ~
0 Yes - All easement locations, types and dimensions are included in plans submitted with this development
application
S No
PART 3 - DEVELOPMENT DETAILS
Section 1 - Aspects of development
6.1) Provide details about the first development aspect
a) What is the type of development? (tick onfyG.ie rex)
0 Material change of use 0 Reconfir" "Ing a lot - O Operational work 0 Building work
b) What is the approval type? (tick only one box)
S Development permit 0 Preliminary approval ' 0 Preliminary aporoval that includes a variation approval
c) What is the level of assessment?
.W _ _ _______ 0___ j
0 Code assessment 0 Impact assessment (requirespbolicnotmdation)
d) Provide a brief description of the proposal (e g. 6 unit apartment building defined as multi-unit dwelling, reconfiguration of 1 lot into 3
tots): r
•______ _
e) Rele' ont plans
Note: Relevant plans are required to be subir&ad for all aspects of this development application. For further information, see OA Forms guide:
Relevant plans.
I S- Relevant plans of the proposed development a.e atteohed to the development application
6.2) Provide details about the second^eve^metft-asileg^- 1
a) What is the type of development? (tick only one box)
J
0 Material change of use 0 Reconfiguring a lot Operational work 0 Building work
b) What is the approval type? (tick only one ‘-'A
0 Development permit 0 Preliminary approval 0 Preliminary approval that includes a variation approval
c) What is the level of assessment?
0 Code assessment I I Impact assessment (requires public notification)
d) Provide a brief description Of the proposal (e g. 6 unit apartment building defined as multi-unit dwelling, reconfiguration of 1 '.ot into 3
tots): ' f
e) Relevant plans
Note: Relevant plans are required to be submitted for all aspects of this development application. For further information, see DA Forms Guide.
Relevant plans.
0 Relevant plans of the proposed deveiopmen, a,e attached to the development application
0 Additional aspects of development'are fo-leyai.i to t.iis rfevblopment application and the details for these aspects
that would be required under Part 3 Section I of this form have been attached to this development application
Q Not required
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DA Form 1 - Development application details
Version 1.3— 28 September 2020
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Section 2 - Further development details
7) Does the proposed development application twelve dhy of the following?
Material change of use 0 Yes - complete division 1 if assessable against a local planning instrument
Reconfiguring a lot Yes - complete division 2
Operational work Yes - complete d.vision 3
Building work Yes -- Jmplete r>A 2 - Building work details
Division 1 - Material change of use *
Note This division is only required to be completed if any part of the development application involves a material change of use assessable against a
local planning instrument.
i I >1^1 i iHf•!■i i ri (SB t^i r ir=i
Provide a general description of the Provide the planning scheme definition Number of dwelling Gross floor
proposed use (include each definition in a new row) units (if applicable) area (m2)
(if applicable)
"/oOA/ £fr|C-i7
fAeoy'TA'f'o^
8.2) Does the proposed use involve th£ use^pf ei itinj^buftdirtgs on the premises?
j Yes
No
Division 2 - Reconfiguring a lot
Note: This division is only required to be completed if any part of the development application involves reconfiqurinq a lot-
9.1) What is the total number of exjglTng lots’ making up th?premises?
9.2) What is the nature of the lot reconfiguration? (tick^ll applica^boxe^ "*
j Subdivision (complete 10)) Dividing land into parts by agreement (complete 11))
I Boundary realignment (complete 12» Creating or changing an easement giving access to a lot
from a constructed ro ad (complete 13))
10) Subdivision ' 's
------------------------------------------------------------------- jjp___ l___=. 'Aw* $ *''' :i "jt***- i ‘ ~ ________ ________
10.1) For this development, how many lots 5r» fejgg creat^j arid^what is the intended use of those lots?
Intended use of lots created Resident^! 'Com'mciCial Industrial Other, please specify:
Number of lots created
10.2) Will the subdivision be staged? *
_____
Yes - provide additional details below
No_______________________ -
How many stages will the works include?- j
What stage(s) will this development application 1
apply to? :
?*•
•V
U‘:
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Version 1.3—28 Sep.ember 2020
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\
11) Dividing land into parts by agreement- Row many parts are being created and what is the intended use of the
parts? -I ' ' 9
Intended use of parts created Residential Commercial Industrial Other, please specify:
Number of parts created
12) Boundary realignment '*
12.1) What are the current and proposed areas f<>e^h |pt flSmprismg the premises? "
Current lot Proposed lot
Lot on plan description Area (m2) Lot on plan description Area (m2)
12.2) What is the reason for the boundary rg'alignmentj’ T %
13) What are the dimensions and nalure 6f any existing easeisents beihg changed and/or any proposed easement?
(attach schedule if there are more than hifo easements) • e ’
Existing or Width (m) Length (m) Purpose of the easement? (e g Identify the land/lot(s)
proposed? pedestran access) benefitted by the easement ,
J
Division 3 - Operational work . • -
Note_This division is only required to be completed if any part of the development application involves operational work.
14.1 )^/Vhat is the nature of the operationalworl^1
4- ’
□ Road work □ otormwafer □ Water infrastructure
□ Drainage work □ Earf’.wc-'ts I-1 Sewage infrastructure
□ Landscaping □ Signage □ Clearing vegetation
□ Other - please specify:
14.2) Is the operational work necessary.to facilitate the cr^atioj of lots?’(e.g. subdivision)
□ Yes - specify number of new lots:
□ No
4.3) What is the monetary value tf the proposed operational work? fOTc/udei.GST. materials and labour)
PART 4 - ASSESSMENT MANAGER DETAILS
15) Identify the assessment manage^) wh^wiftjjg as^e^sir^ this development application as
C W GA
16) Has the local government agreed to a^pl^^^up^rseded planning scheme for this development application?
EJ Yes - a copy of the decision notice is attached to this development application
O The local government is taken to have agreed to the superseded planning scheme request — relevant documents
attached
3-No
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DA Form 1 - Development application details
Version 1 3— 28 September 2020
Page 6
*
PART 5 - REFERRAL DETAILS
17) Does this development application include any aspects that have any reftlrral requirements?
Note A development application will require referral if prescribed by the Planning Relation 2017.
H No, there are no referral requirements re^vant to any development aspects identified in this development
application - proceed to Part 6
_J
Matters requiring referral to the Chief Executive of the Planning Act 2016:
□ Clearing native vegetation
O Contaminated land (unexploded ordnance)
Q Environmentally relevant activities (ERA) (only if the ERA has not been devolved to a local government)
□ Fisheries - aquaculture
□ Fisheries - declared fish habitat area
□ Fisheries - marine plants t
□ Fisheries - waterway barrier works
□ Hazardous chemical facilities
□ Heritage places — Queensland heritage place (ex . or naai a Queensland heritage place)
□ Infrastructure-related referrals - designated premises
□ Infrastructure-related referrals - state transport infrastructure
□ Infrastructure-related referrals - State transport corridor and future State '-ansport corridor
□ Infrastructure-related referrals - State-controlled transport tunne’s and future state-controlled transport tunnels
□ Infrastructure-related referrals - near a state-contrclled road intersection
Q Koala habitat in SEQ region - interfering with koala habitat in koala habitat areas outside koala priority areas
□ Koala habitat, in SEQ region - key resource areas
□ Ports - Brisbane core port land - near a State transport corridor or future State transport corridor
□ Ports - Brisbane core port land - environmentally relevant activity (ERA)
EJ Ports - Brisbane core port land — tidal works or work in a coastal management district
□ Ports - Brisbane core port land - hazardous chemical facility
□ Ports - Brisbane core port land - taking or interfering with water
□ Ports - Brisbane core port land - referable dams
□ Ports - Brisbane core port land - fisheries
□ Ports - Land within Port of Brisbane's port limits (below high-water mark)
□ SEQ development area
rj SEQ regional landscape and rural production area or SEQ rural living area — tourist activity or sport and
recreation activity
□ SEQ regional landscapeand rural production area or S^Q rural living area - community activity
□ SEQ regional landscapeand rural production area or SEQ rural living area — indoor recreation
□ SEQ regional landscapeand rural production area or ?EQ rural living area - urban activity
□ SEQ regional landscapeand rural production area or SEQ rural living area - combined use
□ Tidal works or works in a coastal management district
□ Reconfiguring a lot in a coastal management district or for a canal
□ Erosion prone area in a coastal management district
□ Urban design
□ Water-related development - taking or interfering with water
□ Water-related development - removing quarry material (from a watercourse or lake)
□ Water-related development - referable dams
□ Water-related development -levees (category 3 !o\-eee only)
□ Wetland protection area
Matters requiring referral to the local government:
□ Airport land
EJ Environmentally relevant activities (ERA) {only if the ERA has been devolved to local government)
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DA Form 1 - Development application details
Version 1.3—28 September 2020
Page 7
□ Heritage places - Local heritage places
Matters requiring referral to the Chief Executive of the distribution entity or transmission entity:
□ Infrastructure-related referrals - Electricity infrastructure
Matters requiring referral to:
• The Chief Executive of the holder cf the licence, 'c not an individual
• The holder of the licence, if the holder of the licence is an individual
□ Infrastructure-related referrals - Cil and gas infrastructure
Matters requiring referral to the Brisbane City Council:
□ Ports - Brisbane core port land
Matters requiring referral to the Minister responsible for administering the Transport Infrastructure Act 1994'.
□ Ports - Brisbane core port land (where inconsistent with the Brisbane port LUP for transport reasons)
□ Ports - Strategic port land
Matters requiring referral to the relevant port operator, if applicant is not port operator:
□ Ports - Land within Port of Brisbane’s port limits (beiow high-water mark)
Matters requiring referral to the Chief Executive of the relevant port authority:
□ Ports — Land within limits of another port (below high-water mark)
Matters requiring referral to the Gold Coast Waterways Authority:
□ Tidal works or work in a coastal management district (in Gold Coast waters)
Matters requiring referral to the Queensland Fire and Emergency Service:
□ Tidal works or work in a coastal management district (involving a marina (more than six vessel berths))
18) Has any referral agency prayidfed a referral response for this developmemapplicatiorP ■
1 ‘
— ----- ——--------- -- ' .
I—| Yes - referral response(s) received and listed below a.e attached to this develooment application
No___________
Referral requirement Referral agency Date of referral response
Identify and describe any changes made to the proposed development application that was the subject of the
referral response and this development application, or include details in a schedule to this development aoplication
(if applicable).
PART 6 - INFORMATION REQUEST
S I agree to receive an information request if determined necessary for this development application
□ I do not agree to accept an information request for this development appL.ation
Note By not agreeing to accept an information request I, the applicant, acknowledge:
• that this development application will be assessed and decided based o, i the information provided when making this development
application and the assessment manager and any referral agencies relevant to the development application are not obligated under the DA
Rules to accept any additional information provided by the applicant for the development application unless agreed to by the relevant
padies
• 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 ccntained in the DA Forms Guide.
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OA Form 1 - Development application details
Version 1.3— 23 September 2020
Page 8
PART 7 - FURTHER DETAILS
20) Are there any associated development applicajiongor current approvals? Ye.g. a preliminary approval)
O Yes - provide details below or include details in a schedule to this development application
0 No
List of approval/development Reference number Date Assessment
application references manager
□ Approval
□ Development application
□ Approval
□ Development application
21) Has the portable long service leave levy been paiti? fanfy development applications involving building work or
□ Yes - a copy of the receipted QLeave form is attached to this development application
Q No — I, the applicant will provide evidence that the portable long service leave levy has been paid before the
assessment manager decides the development apolication. I acknowledge that the assessment manager may
give a development approval only if I provide evidence that the portable long service leave levy has been paid
0 Not applicable (e g. building and construction work is less than $150,000 excluding GST)
Amount paid Date paid (dd/mm/yy) QLeave levy number (A, B or E)
$
22) Is, th is development application in response^p a show cause hotice or required as a result of an enforcement
□ Yes - show cause or enforcement notice is attached
| E No
23) Further legislative requirements / ’ ’ ■"Xj '
Environmentally relevant activities .4*- -
23.1) Is this development applicatiomalsottaken to-be an application for an environmental authority tor an1 1
Envirojimentally Relevant Activity (ERA) undgr section IJS olthe Environmental Protection Act 1994?
Q Yes - the required attachment (form ESR/2015/1791) for an application for an environmental authority
accompanies this development application, and details are provided in the lable below
B No
Note: Application for an environmental authority can be found by searching “ESR/20.15/1791" as a search term at www.uld.qov.au. An ERA
requires an environmental authority to operate. See www.bt'siness.qld go'.:au for further information.
Proposed ERA number: I Proposed ERA threshold
Proposed ERA name:
□ Multiple ERAs are applicable to this developpient application and the details have been attached in a schedule to
this development application.
Hazardous chemical facilities ; ,
23.2) Is this development application for a hateardous chamical facility?
□ Yes - Form 69: Notification of a facility exceeding 10% of schedule 15 threshold is attached to this development
application
S No ►>
> #
Note: See w^^busjness.q/d.gov.au for.further information about hazardous'Chemical notifications.
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DA Form 1 - Development application details
Version 1.3— 28 September 2020
Page 9
Clearing native vegetation . * .
23.3) Does this development application involve clearingjiative vegetation that requires written confirmation that
the chief executive of the Vegetation Management Act* 1999 is satisfied the clearing is for a relevant purpose under
section 22A of the Vegetation Management Act 1999? *■ ,
□ Yes - this development application includes written confirmation from the chief executive of the Vegetation
Management Act 1999 (s22A determination)
□ No
Note: 1. Where a development application for operational work or material change of use requires a s22A determination and this is not included,
the development application is prohibited development.
2 See bttP.s;//www. qld. qov. au/environmeni/land/vegetauon/applyina for further information on how to obtain a s22A determination.
Environmental offsets “
* ’w
23.4) Is this development application taken to be a prescribed activity that may have a significant residual impact on
a prescribed environmental matter under the ^nytro/j/ne/tta/ Offset Act 20142
□ Yes I acknowledge that an environmental offset must be provided for any prescribed activity assessed as
having a significant residual impact on a. prescribed environmental matter
No \
| Note. The environmental offset section of the Queensl^r d Government's website can be accessed at www. qld. qov.au for further information on
environmental offsets. . " ■
Koala habitat in SEQ Region ,a, .. •
23.5) Does this development application involve a material change of use, reconfiguring a lot or operational work
which is assessable development under Schedule ’10, Part 1 Cfbf-the Planning. Regulation 2017?
S Yes - the development application involves premises in the koala habitat area in the koala priority area
□ Yes - the development application involves premises in the koala habitat a ea outside the koala priority area
{□No
Note: If a koala habitat area determination has been obtained for this premises and is current over the land, it should be provided as part of this
j development application. See koala habitat area guidance materials at wwyv. des. Qld.qov. au for further information.
Water resources ‘ - 'i
23 6) Does this development application inyol/e takingomnterfering with underground water through an
artesian or subartesidn bore, taking br4nterfering with water in a watercourse, lake or spring, or taking
overland flow water under the Water Act ZOOOP ♦ ■> . '
□ Yes - the relevant template is completed and attache 4 to this development application and I acknowledge that a
relevant authorisation or licence under the Water Act 2ri00 may be required prior to commencing development
□ No ■ “
Note Contact the Department of Natural Resources, Mines and Energy at www. dnrme. qld.qov.c.j for further information.
DA templates are available from https://planninq.dsdmip. qld.gov, au/ If development application involves:
• Taking or interfering with underground water through an artesian or suba^esian borb: complete DA Form 1 Template 1
» Taking or interfering with water in a watercourse, lake or spring: complete DA Form 1 Template 2
• Taking overland flow water: complete DA Form 1 Template 3.
Waterway barrier works z :
23.7) Does this application involve waterway barrier works? 1)
O Yes - the relevant template is completed and attached to this development application
0 No
DA templates are available from https://plannmp.c!sdmip.gid acv.au/. Far a development application involving waterway barrier works, complete
DA Form 1 Template 4. ' -
Marine activities * ’ -i> ir. "u
23.8)*Does this development application' iflvojyeaquftculture, works within ^declared fish habitat area of
removal, disturbance or destruction of marine |aJants> M r
□ Yes - an associated resource allocation authority is attached to this development application, if required under
the Fisheries Act 1994
•S No
Note See guidance materials at www.daf.gld.qov.au for further information. >.
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DA Form 1 - Development application details
Version 1.3— 28 September 2020
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Quarry materials from a watercourse or lake . ./
23.9) Does this development application involve Ifie Kamova I of quarry materials from a watercourse or lake
under
—. the Water Act 2000? ____ . <«».- ' • ____ ,____ .___ _
Yes I acknowledge that a quarry material allocation notice must be obtained prior to commencing development
SNo
Note Contact the Department of Natural Resources, Mines and Energy at www. dnrme. qld qov.au and www. business, qld. gov, au for further
information.
Jr r--..
Quarry materials from land under tidal waters
23 10) Does this development application involve the removal of quarry materials from land under tidal water
under the Coastal Protection and Management Act 1995? ~
Yes I acknowledge that a quarry material allocation notice must be obtained prior to commencing development
No
Note: Contact the Department of Environment and Science at '•'ww.des.qld.pov.au for further information.
Referable dams ‘
23.11) Does this development application irWoif/e^'refer^ble dam required to be failure impact assessed under
sectiori; 343 of the Water Supply (Safety and Reliability)'*Act 2008 (the Water Supply Act)?
Yes - the 'Notice Accepting a Failure Impact Assessment' from the chief executive administering the Water
Supply Act is attached to this development application
No ■-
Note: See guidance materials at www.dnrme.qld.qov.au for further information.
Tidal work or development within jf coastal management district II
23.12) Does this development application invplve tida|werk or de^elqgpient in a coastal management district?
Yes - the following is included with this development application:
Evidence the proposal meets the code for assessable development that is prescribed tidal work (only required \
if application involves prescribed tidal work)
A certificate of title
0 No
Note: See guidance materials at www.des.ald.cov.au for further information.
Queensland and local heritage placef / ' ———
23.13) Does this development application propose develoi9rq£.nt on or'adjoirWg a place»entered in the Queensland
heritage register or on a place entered in ^QcaHfrov^rfrqent’s Local Heritage Register?
Yes - details of the heritage place are provided in the table below
No
Note See guidance materials at wwyr,des.qld.qov.au for information requirements regarding development of Queensland heritage places
Name of the heritage place: [ I Place ID:
Brothels ♦ ** . *'*...
----------------------------------------- « . * ■
C □
23.14) Does this development application involve a matepaj chancffe 6f. use for a brothel?
Yes - this development application demonstrates how the proposal meets the code for a development
application for a brothel under Schedule 3 of the Prostitution Regulation 2014
H No
Decision under section 62 ofthe Ti^p^port Infrastgjctur6 ACH994 ?
Does this development applicatjonjnvOlve newjir changgd1 access to,g.state-controlled road?
Yes - this application will be taken tc be an application fppa decision under section 62 of the Transport
Infrastructure Act 1994 (subject to the conditions in section 75 of the Transport Infrastructure Act 1994 being
I satisfied) t
No - ‘
I '
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Version 1.3—28 September 2020
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Walkable neighbourhoods assessment.benchmarks under Schedule-12A of the Planning Regulation
23.16) Does this development application involve reconfiguring a lot into 2 or more lots in certain residential zones
(except rural residential zones), where at least one,road is created or extended?-'
□ Yes - Schedule 12A is applicable to the development application and the assessment benchmarks contained in
schedule 12A have been considered
"0 No
Note: See guidance materials at www.planning, dsdmip.qld. c.ov.au for further information.
J
PART 8 - CHECKLIST AND APPLICANT DECLARATION
24) Development application checklist
I have identified the assessment manager in question 15 and ait relevant referral
requirement(s) in question 17 es
Note: See the Planning Regulation 2017 for referral requirements
If building work is associated with the proposed development, Parts 4 to 6 of DA Form 2 - □ Yes
Building work details have been completed and attached to this development application E Not applicable
Supporting information addressing any applicable assessment benchmarks is with the
development application
Note: This is a mandatory requirement and includes any relevant templates under question 23 a planning report rCK/es
and any technical reports required by the relevant categorising instruments (e g. local govemmert planning
schemes, 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 aspjcts cfthis development application. For further es
information, see DA Forms Guide: Relevant plans.
The portable long service leave levy for QLeave has been paid, or will be paid before a □ Yes
development permit is issued (see 21) ■
E Not applicable
0 By making this development appkcation, I declare that all it,formation in this development application is true and
correct
ET Where an email address is provided in Part 1 of this form, I consent to receive future electronic communications j
from the assessment manager and any referral agency for the developme u application where written information
is required or permitted pursuant to sections 11 and 12 of the Electronic Ti .insacticns 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 assessment manager and/or chosen
assessment manager, any relevant referral agency and/or building certifier (including any professional advisers
which may be engaged by those entities) while processing, assessing and deciding the development application.
All information relating to this development 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 cbout 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.
Page 11
□A Form 1 - Development application details
Version 1.3—28 September 2020
Page 12
PART 9 - FOR COMPLETION OF THE ASSESSMENT MANAGER - FOR OFFICE
USE ONLY
Date received: Reference number(s):
Notification of engagement of alternative* assessment-rhanager
Prescribed assessment manager dis
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 ’ ■
/Vote. For completion by assessment manager if applicable
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
Page 12
DA Form 1 - Development application details
Version 1.3— 28 September 2020