0014CBAC.001

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             INTEGRATED PLANNING ACT 1997                                                                                  Part E, Version 2.0, 4 October 2004
             by law to “sight” an approved form, issued by |5, Has the PLSL levy been paid?
             Qleave, which signifies that the PLSL levy
             has been paid.                           Whe. — completeQ6
                                                             O ~ the applicable levy must be paid before a development permit can be given for the works
                                                  6.   How much was paid?

                                                  7.   What is the receipt number of the payment?

                                                                        PLEASE NOTE                    .
                                           This application cannot be accepted unless accompanied by Part A of Form 1.                                        '
            "The assessment manager may refuse to accept an application that, at the time of lodgement, fails to provide all applicable information              "
                                                     requested by Part A and any other refevant part of Form 1.
              OFFICE USE ONLY (applicable fo assessment manager}                                                                                              '

             (i)   Is a PLSL levy applicable in this instance?                 LINO                  (2 YES - complete Qti9
    @        (ii)  Has the approved form (issued by QLeave and which signifies that the PLSL levy has been paid) been sighted by the assessment
                   manager / private certifier at the time of lodgement of this application?  LINO             (1 YES - provide receipt details below

                                                                                                                   9 RECEIVED                       \

                                                                                                                   \           FRONT COUNTER        0,
                                                                                                                                              a
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