- Request to change existing approval / Extend relevant period · 132001.210011.1

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4. Location of the premises
~nit    No.                    Street No -;l.:S'l _2~ S      Street        G'I~f\ I::.
                                    -----
 Suburb              N uuS; /hi' LL<:::""                                          State                      Postcode
 Lot no.                       Plan type & plan no.
              4-------         sf' \S08 '-I- I




 5. Concurrence     Agencies
 Was there one or more concurrence agencies involved in the original approval?                     .R_N_o        _
                                                                                                    o Yes-provide details below
 Note - Under s372 of the Suslainable Planning Act 2009 the person making the request is required to give a copy of this request to all
 concurrence agencies.
 Concurrence      Agency                                                                           I Date copy given




                                                                                                                                         j
 6. Pre-request    response notice

I Has a pre-request response been given by~=,evant           en~tity(e.g. a concurrence ag!lncy) for_t_h_is_r_e_q_u_es_t_?               ~
       No                                                      0 Yes
                                                         ---           -----       -    --        -
y yes, please attach a copy of the notice.                                               _                         ._


 7. Owner's consent
 Is the owner's consent required for this request?                    I   0 No                                                               I
                                                                      '113Yes-
                                                                          .    complete either Table A or Table B be/o-w-S-e.-e-~--              J-....J
 Note - If more than one owner of the land all owners' details are required


 Table A - owner's consent provided on form                                  Table B - owner's consent provided          on form

 Owner's name/s&..:::D-=t-C.df'                .           ---l              Owner's namels             l;/!!'1l ~,""
                                                                                                                 ~                 ~ ~

                                                     -
 Itwe, the above-mentioned ownerls of the land. consent
                                                              -i
                                                                             ~he       owner's written consent is ~_.e_d ..            _
 to the making of this request.

 Signaturels


 Date




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