Revised DA FORM 1 - Driverway

Page 2

PART 2 — LOCATION DETAILS

  

  

3) Location of the premises (complete 3.1) or 3.2)
Note: Provide deta
Imei EM eT

  

1d attach a site plan for any or all premises part of the development application. For further information. YB)!
y is ie I ls

  

   
 
  
 
 

3.1) Street address and lot on plan

  

 

 

 

 

 

 

 

CJ Street address AND lot on plan (ail lots must be listed), or
(CJ 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. All lots must be listed).
Unit No. Street No. | Street Name and Type Suburb
) 3 Nairana Rest Noosa Heads
a
Postcode | Lot No. Plan Type and Number (e.g. RP, SP) Local Government Area(s)
4567 110 Rp88934 Noosa
Unit No. | Street No. | Street Name and Type Suburb
b)
Postcode | Lot No. Plan Type and Number (e.g. RP, SP) Local Government Area(s)

 

 

 

 

 

 

 

C1 Coordinates of premises by longitude and latitude
Longitude(s) Latitude(s) Ltyatum Local Govesaffient Area(s) (if applicable) |

: po OC wese4 Lo |

CO Gpag4

LC Other: 7

CL] Coordinates of prempisés | by easting and northing a

Easting(s) 4 + Northing(s). __| Zone Ref. ‘Datam Local Government Area(s) (if applicable)

[(Owesee = =—lEm tt—<“SsCS
1 Gpas4

CJ Other:

 

    
  
  
  

 

 

 

 

   

 

 

   
    
 

 

 

 
 
 
  
 

3.3) Additional premises

     

CJ Additional premjseg are relevant to this development a
attached in a schedule to this development application
(J Not required

 
    

pplication and the details of these premises have been

 

4) Identify any of the following that apply to the premises and provide any relevant details
(C1 In or adjacent to a water body or watercourse or in or above an aquifer
Name of water body, watercourse or aquifer: [ SJ.

CJ On strategic port land under the Transport Infrastructure Act 1 994 >
A

 

 

Lot on plan description of strategic port land:
Name of port authority for the lot: ra 1 La
0 Ina tidal area Sf }
Name of local government for the tidal area (if applicable): | A /
Name of port authority for tidal area (if applicable): ae at
(J On airport land under the Airport Assets (Restructuring and Pfsposal) Act 2008

Sf
Name of airport: WA ZA

 

 

 

 

 

 

 

 

 

 

 

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DA Form 1 — Development application details
Version 1.3— 28 September 2020

Page 3

 

(1 Listed on the Environmental Management Register (EMR) under the Environmental Protection Act 1994
EMR site identification: M/A

(1 Listed on the Contaminated Land Register (CLR) under the Environmental Protection Act 1994

CLR site identification: | WA

 

 

 

 

 

 

      

5) Are there any existing easements over the Ot ceeg
Note: E.

ela Ue

 

 

 

nent uses vary throughout Queensland and
affect the proposed development, see DA

 

e identified correctly and accurately. For further i
uide,

 
  

    

C1 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

 
 
  

  

6.1) Provide details about the first development aspect
a) What is the type of developmept? (tick only one box)

 

 

 

 

 

 

(C1 Material change of use ( Reconfiguring a lot CO Operational work C1 Building work

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

[Development permit C1 Preliminary approval CL] Preliminary approval that includes a variation approval

Cc) What is the level of assessment?

[Code assessment CJ 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
lots):

 

RESIDENTIAL DRIVEWAY AMENDED LAYOUT

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

 

 

 
 

(Relevant plans of the proposed development are attached to the development application
6.2) Provide details about the second development aspect
a) What is the type of development? (tick only one box)

 
   

 

 

 

 

 

CJ Material change of use CJ Reconfiguring a lot CJ Operational work C1 Building work

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

LC] Development permit oO Preliminary approval oO Preliminary approval that includes a variation approval
c) What is the level of assessment?

C1 Code assessment CJ 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
lots):

AS ABOVE

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.

 

 

 

(1 Relevant plans of the proposed development are attached to the development application
6.3) Additional aspects of development

C Additional aspects of development are relevant to this development application and the details for these aspects
at would be required under Part 3 Section 1 of this form have been attached to this development application
Not required

 
  

  

 

 

 

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Page 4

Section 2 — Further development details

7) Does the proposed development application involve any of the following?

 
  

  
  

  
 

 

 

 

 

 

Material change of use C] Yes — complete division 1 if assessable against a local planning instrument
Reconfiguring a lot O Yes — complete division 2

Operational work Yes — complete division 3

Building work 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
local planning instrument.

SMD RPL etl XM Ue lc sescte Melty change of use

 

    
  
 

     
      

 

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 (m7?)
(if applicable)

DRIVEWAY 1 110

 

 

 

 

 

8.2) Does the proposed use involve the use of existing buildings on the premises?

 

 

 

LI No

 

 

Division 2 — Reconfiguring a lot
Note: This division is only required to be completed if any part of the development application involves regonfiguring a lot.
9.1) What is the total number of existing lots making up the premises?

 
  
  

    

9.2) What is the nature of the lot reconfiguration? (
C1 Subdivision (complete 10)) oO Dividing Jand into parts by agreement (complete/1))

C1] Boundary realignment (complete 12)) C Creatifig or changing an easement giving agCess to a lot
frorh a constructed road (complete 13))

10) Subdivision

          
  

 

 

 

 

 
 

 

  
 

10.1) For this development, how many lots are being created and what is the intended use of those lots:
Intended use of lots created Residentig Commercial

Agha
V T

     

    
 

     

Industrial

 

Other, please specify:

 

 

 

 

Number of lots created

 
 
 

10.2) Will the subdivision be staged?
(J Yes — provide additional de
C1 No
How many stages will thye“works include? a

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

    
    

dils below

 

 

 

 

 

 

 

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DA Form 1 — Development application details
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Page 5

     
 

11) Dividing land into parts by agreement — how many parts aie being created and what is the intended use of the

parts?
i Commercial
AL) PC

| Number of parts created [Iv [7 ra

  
  

    
   

Intended use of parts created

  
 

Other, please specify:

 

 

 

 

 

 

 

 

 

12) Boundary realignment

12.1) What are the current and eee Elect ielg ee comprising the eee
Current lot _—Proposed lot
Lot on plan description Area (py Lot on plan descfiption Area (m?)

LL ee.

  
 

 

 

 

 
     
   
  
 

 

 

 

 

 

   

    

    

 

    

12.2)

 

   

13) What are the dimensions and nature of any existing easements being ch
(attach schedule if there are more than two

anged and/or any proposed easement?

     
  

asements)

      

 

 

Existing or Width (m) | Length(m) | Purpose of the easement? (e.g. Identify the land/lot(s)
proposed? p_| Pedestrian access) benefitted by the easement
Z| Tf a
a mT

 

 

 

 

 

 

 

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) What is the nature of the operational work?

(1 Road work CO Stormwater (Water infrastructure
(1 Drainage work C Earthworks CO Sewage infrastructure

C1 léndscaping OO Signage LJ Clearing vegetation

on — please specify: DRIVEWAY RE AGLINMENT

14.2) ls the operational work necessary to facilitate the creation of new lots? (e.g. subdivision)

(] Yes — specify number of new lots:
lo

     

   
  

 
 

              
   

 

14.3) What is the monetary value of the proposed Ce ote elar Lal ae RCE MET unt Reitet)

 

PART 4 — ASSESSMENT MANAGER DETAILS

Se Suede sss ener eu Riana ote assessing this development application

16) Has the local government agreed to apply a superseded planning scheme for this development application?

OYes-a copy of the decision notice is attached to this development application

CJ The local government is taken to have agreed to the superseded planning scheme request — relevant documents
attached

1 No

 

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DA Form 1 — Development application details
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Page 6

PART 5 —- REFERRAL DETAILS

      
  

17) Does this development application include any aspects that have any referral requirements?

Note: A development application will require referral if prescribed by
ae U t

  

Planning Regulation 2017.

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

Matters requiring referral to the Chief Executive of the Planning Act 2016:

C Clearing native vegetation

C Contaminated land (unexploded ordnance)

O Environmentally relevant activities (ERA) (only if the ERA has not been devolved to a local government)

C Fisheries — aquaculture

C1 Fisheries — declared fish habitat area

(1 Fisheries — marine plants

C Fisheries — waterway barrier works

(Hazardous chemical facilities

(] Heritage places — Queensland heritage place (on or near a Queensland heritag

(C1 Infrastructure-related referrals — designated premises

C7 Infrastructure-related referrals — state transport infrastructure

(CJ Infrastructure-related referrals — State transport corridor and futuyé State transport corridor

(CJ Infrastructure-related referrals — State-controlled transport tunpéls and future state-controlled transport tunnels

C1 Infrastructure-related referrals — near a state-controlled roag/ntersection

C Koala habitat in SEQ region — interfering with koala habitaf in koala habitat areas outside koala priority areas

C] Koala habitat in SEQ region — key resource areas

(1 Ports - Brisbane core port land — near a State transport corridor or future State transport corridor

C1] Ports — Brisbane core port land — environmentallyfelevant activity (ERA)

C1 Ports — Brisbane core port land — tidal works orfvork in a coastal management district

C1 Ports — Brisbane core port land — hazardous Lhemical facility

(1 Ports — Brisbane core port land — taking oynterfering with water

(1 Ports — Brisbane core port land — referagle dams

C Ports — Brisbane core port land — fishefies

C1 Ports - Land within Port of Brisbane’s port limits (pelow Aigh-Water mark)

LJ SEQ development area

CO SEQ regional landscape and r
recreation activity

CO SEQ regional landscape 9rd rural production arsa or SEQ rural living gfea — community activity

CseEQ regional landscapg’and rural productionlarea or SEQ rural living’area — indoor recreation

C1] SEQ regional landscgfe and rural production area or SEQ rural liying area — urban activity

C] SEQ regional land ape and rural production area or SEQ ruraViiving area — combined use

(CJ Tidal works or wefks in a coastal management district

C Reconfigurin

      

 

 
   
 
 
 
 
  
 
   
 
  
 

   
    
 
   
   
   
   
  
 
 

   

| productiomarea or SEQ rural living area “fourist activity or sport and

lated development — taking or interfering
-related development — removing quarry
C] water-related development — referable dams

C Water-related development sevees (category levees only)
CO Wetland protection area
Matters requiring referral to the local government:

0 Airport land
Oo Environmentally relevant activities (ERA) (only if the ERA has been devolved to local government)

terial (from a watercourse or lake)

 

 

 

 

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DA Form 1 — Development application details
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Page 7

C1 Heritage places — Local heritage places
Matters requiring referral to the Chief Executive of the distribution nee transmission entity:

 

(J Infrastructure-related referrals — Electricity infrastructure
Matters requiring referral to:

* The Chief Executive of the holder of the licence, if no&4n individual
¢ The holder of the licence, if the holder of the licen
(1 infrastructure-related referrals — Oil and gas infra

Matters requiring referral to the Brisbane City Codncil:
C] Ports — Brisbane core port land

Matters requiring referral to the Minister r,
C1 Ports — Brisbane core port land (wh
C Ports — Strategic port land 5

Matters requiring referral to the rélevant port pParator. if applicant is pdt port operator:
C Ports — Land within Port Brisbane's ort limits (below high-water prark)

Matters requiring referra/fo the Chief Executive of the relev: port authority:

0 Ports — Land withjr(limits iN ther port (below high-water ark)

Matters requiringfeferral to 7 dia Coast Waterw: Authority:

C1 Tidal works“or work in a co stal management district (in Gold Coast waters)

pare. referral to the Queensland Fire and Emergency Service:

 

 
  
 

 

 

 
 

 
  

inconsistent with the Brisbane port LUP for tra port reasons)

 

 

 

 

(1 Tidél works or work in a coastal mana ent district (involving a marina (more than six vessel berths)

 

   

  

18) Has any referral agency provided a referral response for this development application?

oO it — referral response(s) received and listed below are attached to this development application
lo

 

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 application
(if applicable).

 

 

 

 

PART 6 — INFORMATION REQUEST

     
 

   

19) Information request under Part 3 of the DA Rules

[WI agree to receive an information request if determined necessary for this development application
(| do not agree to accept an information request for this development application
Note: By not agreeing to accept an information request |, 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 stil! 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.

 
        
     
        
    

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DA Form 1 — Development application details
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Page 8

PART 7 — FURTHER DETAILS

    

   

20)
LWYes — provide details below or include details in a schedule to this development application

C1 No

PVM UN=1 KIA ISctelol Te] development applications or current approvals

 
 

 

 

 

List of approval/development Reference number Date Assessment
appjication references manager
[Approval 20210396 43/08/21 Julianne Belsham
CJ Development application

CJ Approval

C1 Development application

 

 

 

 

 
 

  

21) Has the portable long service leave levy been paid? (only applicable to development applicatic
operational work)

een eR on ae

     
 

[Z| Yes — a copy of the receipted QLeave form is attached to this development application
(1 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

C1 Not applicable (e.g. building and construction work is less than $1 50,000 excluding GST)

Amount paid Date paid (dd/mm/yy) QLeave levy number (A, B or E)
$

 

 

 

 

 

 
 
  

22) Is this development application in response to a show cause notice or required as a result of an enforcement

notice?
S — show cause or enforcement notice is attached

Pyne

  
    

 

 

23.1) Is this development application also taken to be an application for an environmental authority for an
Environmentally Relevant Activity (ERA) under section 115 of the Environmental Protection Act 1994?

C1 Yes - the required attachment (form ESR/2015/1791) for an application for an environmental authority
“mons this development application, and details are provided in the table below
°

  
   

Note: Application for an environmental authority can be found by searching “ESR/2015/1791" as a search term at www.qld.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:

oO Multiple ERAs are applicable to this development 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 hazardous chemical facility?

C1 Yes - Form 69: Notification of a facility exceeding 10% of schedule 15 threshold is attached to this development
pl

af

 

   

 

ication

 

 

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

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Page 9

 
 
  

Clearing native vegetation

   

23.3) Does this development application involve clearing native 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?

C1 Yes - this development application includes written confirmation fro
wenn Act 1999 (s22A determination)
N

  
  
 

    

m the chief executive of the Vegetation

    
 

0

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:/www.aid.gov. au/environment/land/vegetation/applying for further information on how to obtain a s22A determination.

Environmental offsets

 
  

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 Environmental Offsets Act 2014?

  
    

11 Yes -! acknowledge that an environmental offset must be provided for any prescribed activity assessed as
oe a significant residual impact on a prescribed environmental matter
N

   

oO

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.

Koala habitat in SEQ Region

      
 
 
  

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 10 of the Planning Regulation 2017?

CJ Yes — the development application involves premises in the koala habitat area in the koala priority area
C1 Yes - the development application involves premises in the koala habitat area outside the koala priority area
No

Note: /f 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
development application. See koala habitat area guidance materials at www.des.qld.gov.au for further information.

 
 

  
  
     
  

  
  
 

 

Water resources

  

23.6) Does this development application involve taking or interfering with underground water through an
artesian or subartesian bore, taking or Tale MUM UC Cm EME Ciel l crm El titel spring, or taking
overland flow water under the Water Act 2000?

(J Yes ~ the relevant template is completed and attached to this development application and | acknowledge that a
jelevant authorisation or licence under the Water Act 2000 may be required prior to commencing development

Do mune

Note: Contact the Department of Natural Resources, Mines and Energy at www.dnrme.gid.gov.au for further information.

DA templates are available from https‘/planning.dsdmip.ald.gov.au/. If the development application involves:

° — Taking or interfering with underground water through an artesian or subartesian bore: complete DA Form 1 Template 1

¢ — Taking or interfering with water in a watercourse, lake or spring: complete DA Form1 Template 2

¢ _ Taking overland flow water: complete DA Form 1 Template 3.

  
  
 

   

        
 
    
 
  

Waterway barrier works
23.7) Does this application involve waterway barrier works?

oO c — the relevant template is completed and attached to this development application
0

 

DA templates are available from i imip.qid.gov.au/, For a development application involving waterway barrier works, complete
DA Form 1 Template 4.

 

Marine activities

23.8) Does this development application involve aquaculture, works within a declared fish habitat area or
removal, disturbance or destruction of marine plants?

C0 Yes ~ an associated resource allocation authorit
@ Fisheries Act 1994
No
Note: See guidance materials at www. daf.gid.gov.au for further information.

  
      

y is attached to this development application, if required under

 

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Page 10

Quarry materials from a watercourse or lake

23.9) Does this development application involve the removal of quarry materials from a watercourse or lake
under the Water Act 2000?

oe ~ | acknowledge that a quarry material allocation notice must be obtained prior to commencing development
No

Note: Contact the Department of Natural Resources, Mines and Energy at www.dnrme.qid.gov.au and www.business. gid.gov.au for further
information.

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?

C1 Yes — | acknowledge that a quarry material allocation notice must be obtained prior to commencing development
Ke

Note: Contact the Department of Environment and Science at www.des.gid.gov.au for further information.
Referable dams

   

   

    

3.11) Does this development application involve a referable dam required to be failure impact assessed under
section 343 of the Water Supply (Safety and Reliability) Act 2008 (the Water Supply Act)?
C1 Yes — the ‘Notice Accepting a Failure Impact Assessment’ from the chief executive administering the Water
whom Act is attached to this development application
No

 

Note: See guidance materials at www. dnrme.qid.gov.au for further information.
Tidal work or development within a coastal management district

 
  

 

23.12) Does this development application involve tidal work or development in a coastal management district?

C1 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)

A certificate of title

 

No
Note: See guidance materials at www.des.qid.gov.au for further information.
Queensland and local heritage places

 

 

   

 

23.13) Does this development application propose development on or adjoining a place entered in the Queensland
heritage register or on a place entered in a local government's Local Heritage Register?

(Ys — details of the heritage place are provided in the table below
lo

 

Note: See guidance materials at www.des.qid.gov.au for information requirements regarding development of Queensland heritage places.
Name of the heritage place: Place ID:

 

 

 
  
  
  
  
  

   

Brothels

23.14) Does this development application involve a material change of use for a brothel?
C1 Yes - this development application demonstrates how the proposal meets the code for a development
wi

No

  
   

  
 

plication for a brothel under Schedule 3 of the Prostitution Regulation 2014

Decision under section 62 of the Transport Infrastructure Act 1994

 

 
 
 

23.15) Does this development application involve new or changed access to a state-controlled road?

C1 Yes - 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
sgtisfied)

°

  
    

 

 

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Page 11

      

Walkable neighbourhoods assessment benchmarks under Schedule 12A of the Planning Requlation

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?

LC] Yes — Schedule 12A is applicable to the development application and the assessment benchmarks contained in
who 12A have been considered
lo

 
   

      
     
 
 

  

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

PART 8 —- CHECKLIST AND APPLICANT DECLARATION

  
 
 

24) Development application checklist

 

| have identified the assessment manager in question 15 and all relevant referral
requirement(s) in question 17 Ws
Note: See the Planning Regulation 2017 for referral requirements

If building work is associated with the proposed development, Parts 4 to 6 of DA Form2-— []Ye:
Building work details have been completed and attached to this development application [LNG 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 A

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

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

information, see Forms Guide: Relevani

The portable long service leave levy for QLeave has been paid, or will be paid before a [yés
development permit is issued (see 27) (Not applicable

 

   

25) Applicant declaration

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

rect

we 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 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

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.

 

 

 

 

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Page 12

PART 9 — FOR COMPLETION OF THE ASSESSMENT MANAGER - FOR OFFICE
USE ONLY

Date received: LT Reference number(s): [ |

Notification of engagement of alternative assessment atelatelefelg
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
Note: For completion by

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

  
   

 

 

 

 

 

 

 

 

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