Permissible change request

3. Nature of request (please tick ALL applicable categories)

Ol To change the development NN” To change the development O To extend the relevant period
approval conditions before lapsing

Please attach documentation outlining the detail of and the reasons and justification for the requested change or
extension.

4. Location of the premises

Unit No. StreetNo “S Street Mer eiel AWK

Suburb ‘T.@ Yoh. State Q- Postcode GEG
3 T IGZUN
to SPIAZLU

5. Concurrence Agencies
Was there one or more concurrence agencies involved in the original approval? Eto
O Yes-provide details below

Note — Under s372 of the Sustainable Planning Act 2009 the person making the request is required to give a copy of this request to all
concurrence agencies.

Concurrence Agency Date copy given

6. Pre-request response notice

Has a pre-request response been given by a relevant entity (e.g. a concurrence agency) for this request?
No O Yes

If yes, please attach a copy of the notice.

7. Owner's consent
Is the owner’s consent required for this request? EAN
O Yes— complete either Table A or Table B below

Note — If more than one owner of the land all owners’ details are required

Ole el ae eee leh ioCre moat) Table B — owner's consent provided on form
Owner's name/s Owner’s name/s

IWe, the above-mentioned owner/s of the land, consent O The owner's written consent is attached.
to the making of this request.

Signature/s

Date

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