DA Form 1 & Plan

Page 2

 
   
 
  
 

CL Street address AND lot on plan (ai/ots must be listed), OF

(J 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; ail lots must be listed).

Unit No. | Street No.

     

     
  
    
 

Suburb
co

Local Government Area(s)

   
  
    
  

Street Name and Type
ST
Plan Type and Number (e.g. RP, SP)

  

     
   

  
  
 

  
  

Postcod | Lot No.

e

     
      

       

z
Street No.

cH 6
Street Name and Type

SA SHRE
Suburb

   
   
     
  

    
  

      

    

Unit No.

       

Postcod | Lot No.

e

        

     
  
      

Plan Type and Number (e.g. RP, SP) Local Government Area(s)

 

  
 

(1 Coordinates of premises by longitude and latitude
Latitude(s) Datum

LJ wese4
LC ebag4

(Other:

Longitude(s) Local Government Area(s) (if applicable) |

    

      
   
 
   

    
   
 

     
 

C1 Coordinates of premises by easting and northing
Easting(s) Northing(s) _ Zone Ref.

    

    
   
   
 

Datum Local Government Area(s) (if applicable)

       
  
  
 
 

[Osa | Cwesea
| Oss Cl epao4
| (56 (J Other:

   
 

_] Additional premises are relevant to this development application and their details have been attached in a
schedule to this application |
CINot required

 
    

(1 In or adjacent to a water body or watercourse or in or above an aquifer

Name of water body, watercourse or aquifer: Pome Tee |

(J 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:
| [J Ina tidal area
Name of local government for the tidal area (if applicable):

 

 

Name of port authority for tidal area (if applicable):
LD On airport land under the Airport Assets (Restructuring and Disposal) Act 2008

Name of airport:

 

 

(LJ Listed on the Environmental Management Register (EMR) under the Environmental Protection Act 1994
EMR site identification: :
{[] Listed on the Contaminated Land Register (CLR) under the Environmental Protection Act 1994

 

 

 

Page 3

| CLR site identification: ees]

   

(Yes - All easement locations, types and dimensions are included in plans submitted with this development

application
[No

PART 3—- DEVELOPMENT DETAILS

 

Section 1 — Aspects of development

     
 

 

a) What is the type of development? (tick only one box)

L] Material change of use ( Reconfiguring a lot Geena work (1 Building work
b) What is the approval type? (tick only one box)

eee permit (Preliminary approval (J Preliminary approval that includes

a variation approval

 

c) What is the level of assessment?
Code assessment C1 Impact assessment (requires public notification)

d) Provide a brief description of the proposal (e.g. 6 unit apartment building defined as mulli-unit dwelling, reconfiguration of 1 lot into 3
lots):

 

VeHictE CkvSSOVER

 

e) Relevant plans

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

(Relevant plans of the proposed development are attached to the development application

a) What is the type of development? (tick only one box)

 

(J Material change of use (J Reconfiguring a lot (1 Operational work (1 Building work

b) What is the approval type? (tick only one box)

J Development permit (J Preliminary approval (J Preliminary approval that includes a variation
approval

 

c) What is the level of assessment?

(1 Code assessment L] 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 lot into 3
Jots):

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.

(Relevant plans of the proposed development are attached to the development application

 

 

LJ Additional aspects of development are relevant to this development application and the details for these aspects
that would be required under Part 3 Section 1 of this form have been attached to this development application

(Not required

 

 

Page 4

 

Material change of use

Section 2— Further development details

(1 Yes — complete division 1 if assessable against a local planning instrument

  

 

Reconfiguring a lot

(1 Yes — complete division 2

 

Operational work
Building work

Yes — complete division 3
C1 Yes — complete DA Form 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
Jocal planning instrument.

 
   

 
 

Provide a general description of the
proposed use

Provide the planning scheme definition
(include each definition in a new row)

Number of dwelling Gross floor
units (if applicable) area (m*)
(if applicable)

 

 

 

 

 

 

 

OlYes

 

CNo

 

 

 

 

 

Division 2 — Reconfiguring a lot
Note: This division is only required to be completed if any part of the development application involves reconfiguring a lot.

   

 

   

 

(Subdivision (complete 10)) (1 Dividing land into parts by agreement (complete 11)

fal Boundary realignment (complete 12))

 

(1 Creating or changing an easement giving access to a lot
from a construction road (complete 13))

 

       
 
 

Intended use of lots created Residential Commercial Industrial

     

Other, please specify:

 

 

Number of lots created

 

 
 

(Yes — provide additional details below

LI No

 

How many stages will the works include?

 

What stage(s) will this development application
apply to?

 

 

  
    

           

Intended use of parts created | Residential Commercial Industrial Other, please specify:

      
 

 

Number of parts created

 

 

 

 

Page 5

  

  
   

Proposed lot

 

Current lot
Area (m?) Lot on plan description Area (m?)

 

Lot on plan description

 

 

 

 

 

 

 

 

    
   

Existing or Width (m) | Length (m) | Purpose of the easement? (e.g. Identify the land/lot(s)
proposed? pedestrian access) benefitted by the easement

 

 

 

 

 

 

 

 

Division 3 — Operational work
Note: This division is only required to be completed if any part of the development application involves operational work.

   
  

 

CJ Road work (7 Stormwater (1 Water infrastructure
(1 Drainage work (J Earthworks (1 Sewage infrastructure
CJ Landscaping OO Signage (1 Clearing vegetation

C Other — please specify: le Vee ites ck

   
 

 

 

(Yes — specify number of new lots:

[Ano

Lé5$ Thad 9150 K.
PART 4 — ASSESSMENT MANAGER DETAILS

 

   

(J Yes — a copy of the decision notice is attached to this development application
(Local government is taken to have agreed to the superseded planning scheme request — relevant documents

attached
[Ano

 

PART 5 — REFERRAL DETAILS

[7] No, there are no referral requirements relevant to any development aspects identified in this development
application — proceed to Part 6

 

Page 6

a SE
Matters requiring referral to the Chief Executive

of the Planning Regulation 2017:
C Clearing native vegetation

oO Contaminated land (unexploded ordnance)
O Environmentally relevant activities (ERA)
O Fisheries — aquaculture

C1 Fisheries — declared fish habitat area
CO Fisheries — marine plants

O Fisheries — waterway barrier works
(Hazardous chemical facilities

CO Queensland heritage place (on or near a Queensland heritage place)

O1 Infrastructure — designated premises

(C1 Infrastructure — state transport infrastructure

(J Infrastructure — state transport corridors and future state transport corridors

0 infrastructure — state-controlled transport tunnels and future state-controlled transport tunnels
(1 Infrastructure — near a state-controlled road intersection

(J On Brisbane core port land near a State transport corridor or future State transport corridor
(J On Brisbane core port land — ERA

CJ On Brisbane core port land — tidal works or work in a coastal management district

CJ On Brisbane core port land — hazardous chemical facility

(J On Brisbane core port land — taking or interfering with water

CJ On Brisbane core port land — referable dams

CJ On Brisbane core port land - fisheries

LJ Land within Port of Brisbane's port limits

(J SEQ development area

(SEQ regional landscape and rural production area or SEQ rural living area — tourist activity or sport and
recreation activity

(J SEQ regional landscape and rural production area or SEQ rural living area — community activity
LJ SEQ regional landscape and rural production area or SEQ rural living area — indoor recreation
LJ SEQ regional landscape and rural production area or SEQ rural living area — urban activity
(SEQ regional landscape and rural production area or SEQ rural living area— combined use

(J Tidal works or works in a coastal management district

[ Reconfiguring a lot in a coastal management district or for a canal

(J Erosion prone area in a coastal management district

(J Urban design

( Water-related development — taking or interfering with water

(J Water-related development — removing quarry material (from a watercourse or lake)

(J Water-related development — referable dams

(0 Water-related development — construction of new levees or modification of existing levees (category 3 levees only)
(J Wetland protection area

Matters requiring referral to the local government:

(1 Airport land

(J Environmentally relevant activities (ERA) (only if the ERA have been devolved to local government)

C1 Local heritage places

Matters requiring referral to the chief executive of the distribution entity or transmission entity:
C Electricity infrastructure

Matters requiring referral to:

e The Chief executive of the holder of the licence, if not an individual
« The holder of the licence, if the holder of the licence is an individual
CD Oil and gas infrastructure

Matters requiring referral to the Brisbane City Council:

(only if the ERA have not been devolved to a local government)

 

 

 

 

 

Page 7

 

 

Yes — a copy of the receipted QLeave form is attached to this development application

No —1, the applicant will provide evidence that the portable long service leave levy has been paid before the :
assessment manager decides the development application. | acknowledge that the assessment manager may give
a development approval only if | provide evidence that the portable long service leave levy has been paid

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

$ M/E:

(Yes — show cause or enforcement notice is attached
No

 

 

 

 

   

 

 

 

 

(1 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 table below

No

Note: Application for an environmental authority can be found by searching “ESR/2015/1791" as a search term at www.gid.gov.au. An ERA
requires an environmental authority to operate. See www.business.qid.gov.au for further information.

Proposed ERA number: Proposed ERA threshold:
Proposed ERA name:

 

 

 

 

{1 _ Multiple ERAs are applicable to this development application and the details have been attached in a
schedule to this development application.

 

 
    
    
    
     
    

(1 Yes — Form 69: Notification of a facility exceeding 10% of schedule 15 threshold is attached to this development
application
No

Note: See www.business.gld.gov.au for further information about hazardous chemical notifications.

(J 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 https/Avww.gid.gov.au/environment/and/vegetation/applying for further information on haw to obtain a s22A determination.

(1 Yes - | acknowledge that an environmental offset must be provided for any prescribed activity assessed as
haying a significant residual impact on a prescribed environmental matter

No
Note: The environmental offset section of the Queensland Government's website can be accessed at www.gid.gov.au for further information on

environmental offsets.

 

 

Page 8

 

Brisbane core port land
Matters requiring referral to the Minister under the Transport Infrastructure Act 1994:
Brisbane core port land (inconsistent with Brisbane port LUP for transport reasons)
(1 Strategic port land
Matters requiring referral to the relevant port operator:
(Land within Port of Brisbane's port limits (below high-water mark)
Matters requiring referral to the Chief Executive of the relevant port authority:
C1) Land within limits of another port (below high-water mark)

 

Matters requiring referral to the Gold Coast Waterways Authority:
(1 Tidal works, or work in a coastal management district in Gold Coast waters

 

Matters requiring referral to the Queensland Fire and Emergency Service:

 

(1 Tidal works marina (more than six vessel berths)

 

    

(Yes - referral response(s) received and listed below are attached to this development 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 the development application the subject of this form, or include details in a schedule to this
development application (if applicable).

 

 

PART 6 — INFORMATION REQUEST

- | agree to receive an information request if determined necessary for this development application

[J 1 do not agree to accept an information request for this development application

Note: By not agreeing to accept an information request I, the applicant, acknowledge:

* that this development application will be assessed and decided based on 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 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.

 

PART 7 — FURTHER DETAILS

  

ri Ye¥— provide details below or include details in a schedule to this development application

ANo rele AE IOMII NEN ISLE A eee NP LE

 

 

 

 

 

 

 

 

| List of approval/development _| Reference number Date Assessment
application references manager
(Approval
[J Development application NoogA Cowtil
CD Approval
[J Development application

 

 

 

 

Page 9

 

  
  
  

 

1 Yes — the following is included with this development application:

(1 Evidence the proposal meets the code for assessable development that is prescribed tidal work (only required |
if application involves prescribed tidal work)

CIA certificate of title

No

Note: See guidance materials at www.des.gld.gov.au for further information.

(Yes — details of the heritage place are provided in the table below
No

Note: See guidance materials at www.des.qld.gov.au for information requirements regarding development of Queensland heritage places.

Name of the heritage place: Place ID:

 

 

U1 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

 

Decision under section 62 of the Transport Infrastructure Act 1994

 

f ¥§ - this application will be taken to be an application for a decision under section 62 of the Transport
Infrastructure Act 1994 (subject to the conditions in section 75 of the Transport Infrastructure Act 1994 being
satisfied)

No

 

 

 

PART 8 — CHECKLIST AND APPLICANT DECLARATION

 
   

| have identified the assessment manager in question 15 and all relevant referral

requirement(s) in question 17 Yes

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 Not applicable
Oo

 

Supporting information addressing any applicable assessment benchmarks is with

development application

Note: This is a mandatory requirement and includes any relevant templates under question 23, a planning report
and any technical reports required by the relevant categorising instruments (e.g. local government 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 a
Note: Relevant plans are required to be submitted for all aspects of this development application. For further Yes
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)) [ANot applicable

 

 

Page 10

 

 

[Z| By making this development application, | declare that all information in this development application is true and
correct

Where an email address is provided in Part 1 of this form, | consent to receive future electronic communications
from the assessment manager and any referral agency for the development 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 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:

e such disclosure is in accordance with the provisions about public access to documents contained in the Planning
Act 2076 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 9 — FOR OFFICE USE ONLY

 

Date received: RRR eee] Reference number(s): | |

 

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

 

 

 

 

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

 

Page 11

 

 

 

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