Development Application for Permit to Damage Vegetation 116 Blueberry Drive Blackmount · OPW13/0344

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    "’S:’Arethe~e arl)’ curt; tappr vals (e.g.a preliminary app~o" l) associat d"with’tl s~ap~Ii~~fi n"? (N n~.                                     Ill.

                                                                                      II:.  If:!
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     mandat<?ry requirement.)                                       ,.’ ~,’:r
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        o           No     o        Yes-provide details below

        List of approval reference/s                                         Date approved (dd/mm/yy)         Date approval lapses (dd/mm/yy)




    },I~:~’w ~:~ n~e~t!:quired for this application? (Refer to notes at the end of this’form for
                           c                                                                                                   more   information.)"              i’I




     X              No

        o          Yes-complete either Table G, Table H or Table I as applicable


     T,_ble G

     Name of owner/s of the land


     I/We, the above-mentione’d owner/s of the land, consent to the making of this application.

     Signature of owner/s of the land
,




     Date


     Table H

                                                                                                                                                       ,

     Name of owner/s of the land


     o The owner’s written consent is attached or will be provided separately to the assessment manager

     Table I

     Name of owner/s of the land                                                                          "




     o By making this ap~lication, I, the applicant, declare that the.owner has’given written consent to the making of the
     application.



    ’7?D~~sJhe,appli’cation involve"a state resqurce? ~E.~h~ ~ plcmi                                    lv~;t king~ ter r’qu ?f’m~te1~ ,:o~’",,~
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                                         "Yater. Refer to the notes at thE! nd of this form for more information) (Non-m~ndatory \,.
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     X             No                    o             Not identified whether or    0 Yes-complete Table J
                                                       not the application
                                                       involves a State
                                                       resource




     Table J

    Nature of state-owned resource (if identified)




    4                                                                                                                   IDAS form 1---Applcation deta ls
                                                                                                                               Version 2,031 March 2013