0093_001

Department of Infrastructure, Local Government and Planning

 

 

Note: Relevant plans are required to be submitted for all aspects of this development application. For further

information, see DA Forms Guide: Relevant plans.

The portable long service leave levy for QLeave has been paid, or will be paid before a OO Yes
development pennit is issued (see 21)) XJ Not applicable

25) Applicant declaration

J By making this development application, | declare that all information in this development application is true and

correct

&X] 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: ft is unlawful to intentionally provide false or misteading 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
2016 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: [ti‘Céz** Reference number(s): [ |
Notification of engagement of alternative assessment manager

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

 

 

 

 

 

 

 

QLeave notification and payment

 

Ie] elem exOutsy 1-18) ment manager if applicable

Description of the work

QLeave project number

Amount paid ($)

Date paid

Date receipted form sighted by assessment manager

 

 

 

 

 

 

 

 

Page 11
DA Form 1 — Development Application details
Version 1.0—3 July 2017