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Attachment 1 - Form 5 and Owners' Consent
Change application form
Planning Act Form 5 (version 1.2 effective 7 February 2020) made under Section 282 of the Planning Act 2016.
This form is to be used for a change application made under section 78 of the Planning Act 2016. It is important when
making a change application to be aware of whether the application is for a minor change that will be assessed under
section 81 of the Planning Act 2016 or for an other change that will be assessed under section 82 of the Planning Act
2016.
An applicant must complete all parts of this form, and provide any supporting information that the form identifies as
being required to accompany the change application, unless stated otherwise. Additional pages may be attached if
there is insufficient space on the form to complete any part.
Note: All terms used in this form have the meaning given under the Planning Act 2016, the Planning Regulation 2017, or the Development
Assessment Rules (DA Rules).
PART 1 – APPLICANT DETAILS
1) Applicant details
Applicant name(s) (individual or company full name) OZCARE A.C.N. 072 422 925
c/- Ethos Urban
Contact name (only applicable for companies)
Attn: Ashley Everton
Postal address (P.O. Box or street address) GPO Box 1268
Suburb Brisbane
State Qld
Postcode 4000
Country Australia
Email address (non-mandatory) [email protected]
Mobile number (non-mandatory) 0423741892
Applicant’s reference number(s) (if applicable) 7190526
2) Owner’s consent - Is written consent of the owner required for this change application?
Note: Section 79(1A) of the Planning Act 2016 states the requirements in relation to owner’s consent.
Yes – the written consent of the owner(s) is attached to this change application
No
PART 2 – LOCATION DETAILS
3) Location of the premises (complete 3.1) or 3.2), and 3.3) as applicable)
3.1) Street address and lot on plan
Street address AND lot on plan (all lots must be listed), or
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
80 Cooyar Street Noosa Heads
a)
Postcode Lot No. Plan Type and Number (e.g. RP, SP) Local Government Area(s)
4567 9 RP225312 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)
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3.2) Coordinates of premises (appropriate for development in remote areas, over part of a lot or in water not adjoining or adjacent to land
e.g. channel dredging in Moreton Bay)
Note: Place each set of coordinates in a separate row.
Coordinates of premises by longitude and latitude
Longitude(s) Latitude(s) Datum Local Government Area(s) (if applicable)
WGS84
GDA94
Other:
Coordinates of premises by easting and northing
Easting(s) Northing(s) Zone Ref. Datum Local Government Area(s) (if applicable)
54 WGS84
55 GDA94
56 Other:
3.3) Additional premises
Additional premises are relevant to the original development approval and the details of these premises have
been attached in a schedule to this application
Not required
PART 3 – RESPONSIBLE ENTITY DETAILS
4) Identify the responsible entity that will be assessing this change application
Note: see section 78(3) of the Planning Act 2016
Noosa Shire Council
PART 4 – CHANGE DETAILS
5) Provide details of the existing development approval subject to this change application
Approval type Reference number Date issued Assessment
manager/approval entity
Development permit Noosa Shire Council
21675 DA 13 December 2005
Preliminary approval
Development permit
Preliminary approval
6) Type of change proposed
6.1) Provide a brief description of the changes proposed to the development approval (e.g. changing a development
approval for a five unit apartment building to provide for a six unit apartment building):
Change application to development approval 21675 DA dated 7 December 2005 to modify / extend parts of the
existing aged care facility to facilitate the conversion of dual-bed shared rooms to single bedrooms to ensure
the facility meets current legislative and market requirements for aged care accommodation (and in particular
eliminating shared bedrooms/ensuites as an urgent issue of infection control)
6.2) What type of change does this application propose?
Minor change application – proceed to Part 5
Other change application – proceed to Part 6
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Planning Act Form 5 - Change application form
Version 1.2 — 7 February 2020
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PART 5 – MINOR CHANGE APPLICATION REQUIREMENTS
7) Are there any affected entities for this change application
No – proceed to Part 7
Yes – list all affected entities below and proceed to Part 7
Note: section 80(1) of the Planning Act 2016 states that the person making the change application must give notice of the proposal and the
details of the change to each affected entity as identified in section 80(2) of the Planning Act 2016.
Affected entity Pre-request response provided? (where a pre- Date notice given (where no pre-
request response notice for the application has been request response provided)
given, a copy of the notice must accompany this change
application)
No
Yes – pre-request response is attached to
this change application
No
Yes – pre-request response is attached to
this change application
No
Yes – pre-request response is attached to
this change application
PART 6 – OTHER CHANGE APPLICATION REQUIREMENTS
Note: To complete this part it will be necessary for you to complete parts of DA Form 1 – Development application details and in some instances parts
of DA Form 2 – Building work details, as mentioned below. These forms are available at https://planning.dsdmip.qld.gov.au.
8) Location details - Are there any additional premises included in this change application that were not part of the
original development approval?
No
Yes
9) Development details
9.1) Is there any change to the type of development, approval type, or level of assessment in this change
application?
No
Yes – the completed Sections 1 and 2 of Part 3 (Development details) of DA Form 1 – Development application
details as these sections relate to the new or changed aspects of development are provided with this application.
9.2) Does the change application involve building work?
No
Yes – the completed Part 5 (Building work details) of DA Form 2 – Building work details as it relates to the
change application is provided with this application.
10) Referral details – Does the change application require referral for any referral requirements?
Note: The application must be referred to each referral agency triggered by the change application as if the change application was the original
development application including the proposed change.
No
Yes – the completed Part 5 (Referral details) of DA Form 1 – Development application details as it relates to the
change application is provided with this application. Where referral is required for matters relating to building
work the Referral checklist for building work is also completed.
11) Information request under Part 3 of the DA Rules
I agree to receive an information request if determined necessary for this change application
I do not agree to accept an information request for this change application
Note: By not agreeing to accept an information request I, the applicant, acknowledge:
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Planning Act Form 5 - Change application form
Version 1.2 — 7 February 2020
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• that this change application will be assessed and decided based on the information provided when making this change application and the
assessment manager and any referral agencies relevant to the change application are not obligated under the DA Rules to accept any
additional information provided by the applicant for the change 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: Forms 1 and 2.
12) Further details
Part 7 of DA Form 1 – Development application details is completed as if the change application was a
development application and is provided with this application.
PART 7 – CHECKLIST AND APPLICANT DECLARATION
13) Change application checklist
I have identified the:
• responsible entity in 4); and
• for a minor change, any affected entities; and Yes
• for an other change all relevant referral requirement(s) in 10)
Note: See the Planning Regulation 2017 for referral requirements
For an other change application, the relevant sections of DA Form 1 – Development Yes
application details have been completed and is attached to this application Not applicable
For an other change application, where building work is associated with the change Yes
application, the relevant sections of DA Form 2 – Building work details have been
completed and is attached to this application Not applicable
Supporting information addressing any applicable assessment benchmarks is attached to
this application
Note: This includes any templates provided under 23.6 and 23.7 of DA Form 1 – Development application details Yes
that are relevant as a result of the change application, a planning report and any technical reports required by the
relevant categorising instrument(s) (e.g. the local government planning scheme, 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 relevant aspects of this change application. For further Yes
information, see DA Forms Guide: Relevant plans.
14) Applicant declaration
By making this change application, I declare that all information in this change application is true and correct.
Where an email address is provided in Part 1 of this form, I consent to receive future electronic communications
from the responsible entity and any relevant affected entity or referral agency for the change 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 responsible entity and/or chosen
assessment manager, any relevant affected entity or referral agency and/or building certifier (including any
professional advisers which may be engaged by those entities) while processing, assessing and deciding the
change application.
All information relating to this change 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:
• 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
• 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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Planning Act Form 5 - Change application form
Version 1.2 — 7 February 2020
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PART 8 – FOR COMPLETION OF THE ASSESSMENT MANAGER – FOR OFFICE
USE ONLY
Date received: Reference number(s):
QLeave notification and payment
Note: For completion by assessment manager if applicable
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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Planning Act Form 5 - Change application form
Version 1.2 — 7 February 2020
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Company owner’s consent to the making of a development application under the Planning Act 2016 |, Dinuke Christie-David [Insert name in full} Secretary of the company mentioned below. [Delete the above where company owner's consent must come from both director and director/secretary] |, Anthony Godfrey [Insert name in full CEO and Authorised Signatory of the company mentioned below. and |, [insert name in full. position in another director, or a company secretary.} is rector etar company giving the Of Ozcare A.C.N. 072 422 925 the company being the owner of the premises identified as follows: 80 Cooyar Street, Noosa Heads (Lot 9 on RP225312) consent to the making of a development application under the Planning Act 2016 by: Ozcare A.C.N. 072 422 925, c/- Ethos Urban The Planning Act 2016 is administered by the Department of Local Government, Infrastructure and Planning, Queensland Government. Applicant template 11.0 Version 1.0—3 July 2017
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on the premises described above for:
Change application to development approval 21675 DA dated 7 December 2005 / Development Permit
for Material Change of Use for Extension to Residential Care Facility
Company seal [if used]
Company Name and ACN: Ozcare A.C.N. 072 422 925
" Signature of Sole Director/Secretary
“Date
[Delete the above where company owner’s consent must come from both director and director/secretary.]
Company Name and ACN: Ozcare A.C.N. 072 422 925
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[Delete the above where there is @ sole director/secretary for the company giving the owner’s consent.]
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Applicant template 11.0
Version 1.0—3 July 2017
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A Titles Current Title Search Mame QUEENSLAND Queensland Titles Registry Pty Ltd ABN 23 648 568 101 Title Reference: 17299066 Search Date: 14/11/2022 14:35 Date Title Created: 10/04/1989 Request No: 42821745 Previous Title: 13651039 ESTATE AND LAND Estate in Fee Simple LOT9 REGISTERED PLAN 225312 Local Government: NOOSA REGISTERED OWNER Dealing No: 708318556 22/12/2004 OZCARE A.C.N. 072 422 925 EASEMENTS, ENCUMBRANCES AND INTERESTS 1. Rights and interests reserved to the Crown by Deed of Grant No. 10777073 (POR 1653) 2. EASEMENT IN GROSS No 710272147 19/01/2007 at 13:45 burdening the land ENERGEX LIMITED A.C.N. 078 849 055 over EASEMENT A ON SP197575 3. MORTGAGE No 721303791 01/12/2021 at 14:53 COMMONWEALTH BANK OF AUSTRALIA A.C.N. 123 123 124 ADMINISTRATIVE ADVICES NIL UNREGISTERED DEALINGS NIL Caution - Charges do not necessarily appear in order of priority ** End of Current Title Search ** COPYRIGHT QUEENSLAND TITLES REGISTRY PTY LTD [2022] www.titlesqid.com.au Requested by: D-ENQ CITEC CONFIRM Page 1/1