59 Witta IDAS form 1 ans 6 · OPW13/0216

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Privacy—the information collected in this form will be used by the Department of Infrastructure and Planning (DIP) in
accordance with the Processing and assessment of your application. Your personal details will not be disclosed fora purpose
outside of the IDAS process, except where required by legislation (including the Right to Information Act 2009) or as required
by Parliament. This information may be stored in a departmental database. The information collected will be retained as
required by the Public Records Act 2002.

 

OFFICE USE ONLY

Date received LT Reference numbers

NOTIFICATION OF ENGAGEMENT OF A PRIVATE CERTIFIER

To Council. | have been engaged as the private certifier for the building work referred
to in this application

bm ‘ane
ae Building
Date of engagement Name BSA Certification license number see ge
classification/s

 

 

 

 

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QLEAVE NOTIFICATION AND PAYMENT (for completion by assessment Manager or private certifier if applicable)

 

Date receipted |
pe QLeave Project Amount paid a form sighted by |Name of officer who
Description of the work Number ($) Date paid assessment sighted the form
manager

 

 

 

 

 

 

 

 

 

 

The Sustainable Planning Act 2009 (SPA) is administered by the Department of Infrastructure and Planning. This form and
all other required application materials should be sent to your assessment manager and any referral agencies.

 

wr X Application details—IDAS form 1
Version 1.0 18 December 2009