DAForm5-Changeapplicationform.docx

Change application form
Planning Act Form 5 (version 1.2 effective 7 February 2020) made under Section 282 of the Planning Act 2016.

This form is to be used for a change application made under section 78 of the Planning Act 2016. It is important when making a change application to be aware of whether the application is for a minor change that will be assessed under section 81 of the Planning Act 2016 or for an other change that will be assessed under section 82 of the Planning Act 2016.
An applicant must complete all parts of this form, and provide any supporting information that the form identifies as being required to accompany the change application, unless stated otherwise. Additional pages may be attached if there is insufficient space on the form to complete any part.
Note: All terms used in this form have the meaning given under the Planning Act 2016, the Planning Regulation 2017, or the Development Assessment Rules (DA Rules).

PART 1 – APPLICANT DETAILS

1) Applicant details
Applicant name(s) (individual or company full name)	Davrus Pty Ltd c/ Pivotal Perspective Pty Ltd
Contact name (only applicable for companies)	Jack Lewis
Postal address (P.O. Box or street address)	4/59 Mary Street
Suburb	Noosaville
State	QLD
Postcode	4565
Country	Australia
Email address (non-mandatory)	[email protected]
Mobile number (non-mandatory)	0406 334 227
Applicant’s reference number(s) (if applicable)	0255

2) Owner’s consent - Is written consent of the owner required for this change application? Note: Section 79(1A) of the Planning Act 2016 states the requirements in relation to owner’s consent.
Yes – the written consent of the owner(s) is attached to this change application X No

PART 2 – LOCATION DETAILS

3) Location of the premises (complete 3.1) or 3.2), and 3.3) as applicable)
3.1) Street address and lot on plan
X Street address AND lot on plan (all lots must be listed), or Street address AND lot on plan for an adjoining or adjacent property of the premises (appropriate for development in water but adjoining or adjacent to land e.g. jetty, pontoon. All lots must be listed).
a)	Unit No.	Street No.	Street Name and Type	Suburb
		89-93
	Postcode	Lot No.	Plan Type and Number (e.g. RP, SP)	Local Government Area(s)
		1RP130594, 80-81RP71151	Noosa
3.2) Coordinates of premises (appropriate for development in remote areas, over part of a lot or in water not adjoining or adjacent to land e.g. channel dredging in Moreton Bay) Note: Place each set of coordinates in a separate row.
Coordinates of premises by longitude and latitude
Longitude(s)	Latitude(s)	Datum	Local Government Area(s) (if applicable)
		WGS84 GDA94	
		Other:		
Coordinates of premises by easting and northing
Easting(s)	Northing(s)	Zone Ref.	Datum	Local Government Area(s) (if applicable)
		54 55 56	WGS84 GDA94	
			Other:		
3.3) Additional premises
Additional premises are relevant to the original development approval and the details of these premises have been attached in a schedule to this application x Not required

PART 3 – RESPONSIBLE ENTITY DETAILS

4) Identify the responsible entity that will be assessing this change application Note: see section 78(3) of the Planning Act 2016
Noosa Council

PART 4 – CHANGE DETAILS

5) Provide details of the existing development approval subject to this change application
Approval type	Reference number	Date issued	Assessment manager/approval entity
X Development permit Preliminary approval	MCU21/0156	2022	Noosa
Development permit Preliminary approval			

6) Type of change proposed
6.1) Provide a brief description of the changes proposed to the development approval (e.g. changing a development approval for a five unit apartment building to provide for a six unit apartment building):
Minor Change – Condition 42c
6.2) What type of change does this application propose?
x Minor change application – proceed to Part 5 Other change application – proceed to Part 6

PART 5 – MINOR CHANGE APPLICATION REQUIREMENTS

7) Are there any affected entities for this change application
x No – proceed to Part 7 Yes – list all affected entities below and proceed to Part 7 Note: section 80(1) of the Planning Act 2016 states that the person making the change application must give notice of the proposal and the details of the change to each affected entity as identified in section 80(2) of the Planning Act 2016.
Affected entity	Pre-request response provided? (where a pre-request response notice for the application has been given, a copy of the notice must accompany this change application)	Date notice given (where no pre-request response provided)
	No Yes – pre-request response is attached to this change application	
	No Yes – pre-request response is attached to this change application	
	No Yes – pre-request response is attached to this change application	

PART 6 – OTHER CHANGE APPLICATION REQUIREMENTS
Note: To complete this part it will be necessary for you to complete parts of DA Form 1 – Development application details and in some instances parts of DA Form 2 – Building work details, as mentioned below. These forms are available at https://planning.dsdmip.qld.gov.au.

8) Location details - Are there any additional premises included in this change application that were not part of the original development approval?
x No Yes

9) Development details
9.1) Is there any change to the type of development, approval type, or level of assessment in this change application?
No Yes – the completed Sections 1 and 2 of Part 3 (Development details) of DA Form 1 – Development application details as these sections relate to the new or changed aspects of development are provided with this application.
9.2) Does the change application involve building work?
No Yes – the completed Part 5 (Building work details) of DA Form 2 – Building work details as it relates to the change application is provided with this application.

10) Referral details – Does the change application require referral for any referral requirements? Note: The application must be referred to each referral agency triggered by the change application as if the change application was the original development application including the proposed change.
No Yes – the completed Part 5 (Referral details) of DA Form 1 – Development application details as it relates to the change application is provided with this application. Where referral is required for matters relating to building work the Referral checklist for building work is also completed.

11) Information request under Part 3 of the DA Rules
X I agree to receive an information request if determined necessary for this change application I do not agree to accept an information request for this change application Note: By not agreeing to accept an information request I, the applicant, acknowledge: that this change application will be assessed and decided based on the information provided when making this change application and the assessment manager and any referral agencies relevant to the change application are not obligated under the DA Rules to accept any additional information provided by the applicant for the change application unless agreed to by the relevant parties Part 3 of the DA Rules will still apply if the application is an application listed under section 11.3 of the DA Rules. Further advice about information requests is contained in the DA Forms Guide: Forms 1 and 2.

12) Further details
X Part 7 of DA Form 1 – Development application details is completed as if the change application was a development application and is provided with this application.

PART 7 – CHECKLIST AND APPLICANT DECLARATION

13) Change application checklist
I have identified the: responsible entity in 4); and for a minor change, any affected entities; and for an other change all relevant referral requirement(s) in 10) Note: See the Planning Regulation 2017 for referral requirements	X Yes
For an other change application, the relevant sections of DA Form 1 – Development application details have been completed and is attached to this application	Yes x Not applicable
For an other change application, where building work is associated with the change application, the relevant sections of DA Form 2 – Building work details have been completed and is attached to this application	Yes X Not applicable
Supporting information addressing any applicable assessment benchmarks is attached to this application Note: This includes any templates provided under 23.6 and 23.7 of DA Form 1 – Development application details that are relevant as a result of the change application, a planning report and any technical reports required by the relevant categorising instrument(s) (e.g. the local government planning scheme, State Planning Policy, State Development Assessment Provisions). For further information, see DA Forms Guide: Planning report template.	X Yes
Relevant plans of the development are attached to this development application Note: Relevant plans are required to be submitted for all relevant aspects of this change application. For further information, see DA Forms Guide: Relevant plans.	X Yes

14) Applicant declaration
X By making this change application, I declare that all information in this change application is true and correct. X Where an email address is provided in Part 1 of this form, I consent to receive future electronic communications from the responsible entity and any relevant affected entity or referral agency for the change application where written information is required or permitted pursuant to sections 11 and 12 of the Electronic Transactions Act 2001. Note: It is unlawful to intentionally provide false or misleading information.
Privacy – Personal information collected in this form will be used by the responsible entity and/or chosen assessment manager, any relevant affected entity or referral agency and/or building certifier (including any professional advisers which may be engaged by those entities) while processing, assessing and deciding the change application. All information relating to this change application may be available for inspection and purchase, and/or published on the assessment manager’s and/or referral agency’s website. Personal information will not be disclosed for a purpose unrelated to the Planning Act 2016, Planning Regulation 2017 and the DA Rules except where: such disclosure is in accordance with the provisions about public access to documents contained in the Planning Act 2016 and the Planning Regulation 2017, and the access rules made under the Planning Act 2016 and Planning Regulation 2017; or required by other legislation (including the Right to Information Act 2009); or otherwise required by law. 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	
QLeave project number	
Amount paid ($)		Date paid (dd/mm/yy)	
Date receipted form sighted by assessment manager	
Name of officer who sighted the form	

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

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Department of State Development, Infrastructure and Planning

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