09/1058 Request to Change Existing Approval and/or Extension to Relevant Period 1320009.1058.03 · 132009.1058.03

3. Nature of request (please tick ALL applicable categories)
Cd' To change the development                 q    To change the development               q    To extend the relevant period
    approval                                       conditions                                   before lapsing
Please attach documentation outlining the detail of and the reasons and justification for the requested change or
extension.



4. Location of the premises
Unit No.                      Street No        $            Street
Suburb                           ^^                                          State     Q                  Postcode     41-s-N.S
Lot no.                       Plan type & plan no.
     b5




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




6. Pre-request response notice
Has a pre-request response been given by a relevant entity (e.g. a concurrence agency) for this request?
[? Jo                                                            D Yes
If yes, please attach a copy of the notice.


7. Owner's consent
Is the owner's consent required for this request?                    q No
                                                                     2/Yes- complete either Table A or Table B below
Note - If more than one owner of the land all owners' details are required


Table A - owner's consent provided on form
                                  V"', C l_, { C L_^.?•i
Owner's namels        ^`
                                                                         Table A - owner's consent provided on form
I/1Ne, the above-mentioned ownerls of the land, consent
to the making of this rgquest.                                           Owner's name/s

Signature/s                                                              q The owner's written consent is attached.




2 of 4     2011112 Regional Strategy and Planning Request to Change Existing Approval and'o- Extens!on to Relevant Period FM401