Planning Act Form 5 - Change application form (1) · 132001.210326.1

 This information may be stored in relevant databases. The information collected will be retained as required by the
 Public Records Act 2002.

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                                             Alterations/Additions to Dwelling
 QLeave project number                                               S385299
 Amount paid ($)              $11,212.00                             Date paid (dd/mm/yy)            12/08/2024
 Date receipted form sighted by assessment manager                   12/08/2024
 Name of officer who sighted the form                                Stewart Magill




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                                                                                       Planning Act Form 5 - Change application form
                                                                                                      Version 1.2 — 7 February 2020