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DA Form 1 - Development application details - Other change.pdf
DA Form 1 – Development application details
Approved form (version 1.3 effective 28 September 2020) made under section 282 of the Planning Act 2016.
This form must be used to make a development application involving code assessment or impact assessment,
except when applying for development involving only building work.
For a development application involving building work only, use DA Form 2 – Building work details.
For a development application involving building work associated with any other type of assessable development
(i.e. material change of use, operational work or reconfiguring a lot), use this form (DA Form 1) and parts 4 to 6 of
DA Form 2 – Building work details.
Unless stated otherwise, all parts of this form must be completed in full and all required supporting information must
accompany the development application.
One or more additional pages may be attached as a schedule to this development application if there is insufficient
space on the form to include all the necessary information.
This form and any other form relevant to the development application must be used to make a development
application relating to strategic port land and Brisbane core port land under the Transport Infrastructure Act 1994,
and airport land under the Airport Assets (Restructuring and Disposal) Act 2008. For the purpose of assessing a
development application relating to strategic port land and Brisbane core port land, any reference to a planning
scheme is taken to mean a land use plan for the strategic port land, Brisbane port land use plan for Brisbane core
port land, or a land use plan for airport land.
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) Noosa Springs Real Estate Pty Ltd
Contact name (only applicable for companies) Phil Starkey, Project Manager, GH Australia
Care/- Adamson Town Planning Pty Ltd
Postal address (P.O. Box or street address) PO Box 894
Suburb Cooroy
State QLD
Postcode 4563
Country Australia
Contact number 07 5430 6671
Email address (non-mandatory) [email protected]
Mobile number (non-mandatory) 0437 754 420
Fax number (non-mandatory)
Applicant’s reference number(s) (if applicable) 16022
2) Owner’s consent
2.1) Is written consent of the owner required for this development application?
Yes – the written consent of the owner(s) is attached to this development application
No – proceed to 3)
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DA Form 1 — Development application details
Approved form (version 1.3 effective 28 September 2020) made under section 282 of the Planning Act 2016.
This form must be used to make a development application involving code assessment or impact assessment,
except when applying for development involving only building work.
For a development application involving building work only, use DA Form 2-— Building work details.
For a development application involving building work associated with any other type of assessable development
(i.e. material change of use, operational work or reconfiguring a lot), use this form (DA Form 1) and parts 4 to 6 of
DA Form 2- Building work details.
Unless stated otherwise, all parts of this form must be completed in full and all required supporting information must
accompany the development application.
One or more additional pages may be attached as a schedule to this development application if there is insufficient
space on the form to include all the necessary information.
This form and any other form relevant to the development application must be used to make a development
application relating to strategic port land and Brisbane core port land under the Transport Infrastructure Act 1994,
and airport land under the Airport Assets (Restructuring and Disposal) Act 2008. For the purpose of assessing a
development application relating to strategic port land and Brisbane core port land, any reference to a planning
scheme is taken to mean a land use plan for the strategic port land, Brisbane port land use plan for Brisbane core
port land, or a land use plan for airport land.
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) Noosa Springs Real Estate Pty Ltd
Contact name (only applicable for companies) Phil Starkey, Project Manager, GH Australia
Care/- Adamson Town Planning Pty Ltd
Postal address (P.O. Box or street address) PO Box 894
Suburb Cooroy
State QLD
Postcode 4563
Country Australia
Contact number 07 5430 6671
Email address (non-mandatory) [email protected]
Mobile number (non-mandatory) 0437 754 420
Fax number (non-mandatory)
Applicant's reference number(s) (if applicable) 16022
2) Owner’s consent
2.1) Is written consent of the owner required for this development application?
V1 Yes — the written consent of the owner(s) is attached to this development application
LJ No - proceed to 3)
x Queensland
x) Government
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Page 2
PART 2 – LOCATION DETAILS
3) Location of the premises (complete 3.1) or 3.2), and 3.3) as applicable)
Note: Provide details below and attach a site plan for any or all premises part of the development application. For further information, see DA
Forms Guide: Relevant plans.
3.1) Street address and lot on plan
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).
Unit No. Street No. Street Name and Type Suburb
Links Drive Noosa Heads
a)
Postcode Lot No. Plan Type and Number (e.g. RP, SP) Local Government Area(s)
4567 4 SP178340 Noosa Shire
Unit No. Street No. Street Name and Type Suburb
b)
Postcode Lot No. Plan Type and Number (e.g. RP, SP) Local Government Area(s)
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 WGS84
55 GDA94
56 Other:
3.3) Additional premises
Additional premises are relevant to this development application and the details of these premises have been
attached in a schedule to this development application
Not required
4) Identify any of the following that apply to the premises and provide any relevant details
In or adjacent to a water body or watercourse or in or above an aquifer
Name of water body, watercourse or aquifer:
On strategic port land under the Transport Infrastructure Act 1994
Lot on plan description of strategic port land:
Name of port authority for the lot:
In a tidal area
Name of local government for the tidal area (if applicable):
Name of port authority for tidal area (if applicable):
On airport land under the Airport Assets (Restructuring and Disposal) Act 2008
Name of airport:
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DA Form 1 – Development application details
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PART 2 —LOCATION DETAILS
3) Location of the premises (complete 3.1) or 3.2), and 3.3) as applicable)
Note: Provide details below and attach a site plan for any or all premises part of the development application. For further information, see DA
fei RCI 6 [-a (=) 1-1 oD
3.1) Street address and lot on plan
IVI Street address AND lot on plan (all lots must be listed), or
LJ 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).
Unit No. | Street No. | Street Name and Type Suburb
Links Drive Noosa Heads
a) Postcode | Lot No. Plan Type and Number (e.g. RP, SP) Local Government Area(s)
4567 4 SP178340 Noosa Shire
Unit No. | Street No. | Street Name and Type Suburb
b)
Postcode | Lot No. Plan Type and Number (e.g. RP, SP) Local Government Area(s)
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.
LJ Coordinates of premises by longitude and latitude
Longitude(s) Latitude(s) Datum Local Government Area(s) (if applicable)
LJ] wess4
LJ GDA94
LJ Other:
LJ Coordinates of premises by easting and northing
Easting(s) Northing(s) Zone Ref. | Datum Local Government Area(s) (if applicable)
154 LJ wese4
[55 LJ GDA94
(156 CJ Other:
3.3) Additional premises
LJ Additional premises are relevant to this development application and the details of these premises have been
attached in a schedule to this development application
1 Not required
4) Identify any of the following that apply to the premises and provide any relevant details
LJ In or adjacent to a water body or watercourse or in or above an aquifer
Name of water body, watercourse or aquifer: |
LJ On strategic port land under the Transport Infrastructure Act 1994
Lot on plan description of strategic port land:
Name of port authority for the lot:
CJ In a tidal area
Name of local government for the tidal area (if applicable):
Name of port authority for tidal area (if applicable):
LJ On airport land under the Airport Assets (Restructuring and Disposal) Act 2008
Name of airport:
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Listed on the Environmental Management Register (EMR) under the Environmental Protection Act 1994
EMR site identification:
Listed on the Contaminated Land Register (CLR) under the Environmental Protection Act 1994
CLR site identification:
5) Are there any existing easements over the premises?
Note: Easement uses vary throughout Queensland and are to be identified correctly and accurately. For further information on easements and
how they may affect the proposed development, see DA Forms Guide.
Yes – All easement locations, types and dimensions are included in plans submitted with this development
application
No
PART 3 – DEVELOPMENT DETAILS
Section 1 – Aspects of development
6.1) Provide details about the first development aspect
a) What is the type of development? (tick only one box)
Material change of use Reconfiguring a lot Operational work Building work
b) What is the approval type? (tick only one box)
Development permit Preliminary approval Preliminary approval that includes a variation approval
c) What is the level of assessment?
Code assessment Impact assessment (requires public notification)
d) Provide a brief description of the proposal (e.g. 6 unit apartment building defined as multi-unit dwelling, reconfiguration of 1 lot into 3
lots):
Proposed “Boutique Hotel” in conjunction with the existing Noosa Springs Golf and Spa Resort facilities to provide a
Resort Complex.
e) Relevant plans
Note: Relevant plans are required to be submitted for all aspects of this development application. For further information, see DA Forms guide:
Relevant plans.
Relevant plans of the proposed development are attached to the development application.
6.2) Provide details about the second development aspect
a) What is the type of development? (tick only one box)
Material change of use Reconfiguring a lot Operational work Building work
b) What is the approval type? (tick only one box)
Development permit Preliminary approval Preliminary approval that includes a variation approval
c) What is the level of assessment?
Code assessment Impact assessment (requires public notification)
d) Provide a brief description of the proposal (e.g. 6 unit apartment building defined as multi-unit dwelling, reconfiguration of 1 lot into 3
lots):
e) Relevant plans
Note: Relevant plans are required to be submitted for all aspects of this development application. For further information, see DA Forms Guide:
Relevant plans.
Relevant plans of the proposed development are attached to the development application
6.3) Additional aspects of development
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Version 1.3— 28 September 2020
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LJ Listed on the Environmental Management Register (EMR) under the Environmental Protection Act 1994
EMR site identification: |
CJ Listed on the Contaminated Land Register (CLR) under the Environmental Protection Act 1994
CLR site identification: |
5) Are there any existing easements over the premises?
Note: Easement uses vary throughout Queensland and are to be identified correctly and accurately. For further information on easements and
how they may affect the proposed development, see DA Forms Guide.
V1 Yes — All easement locations, types and dimensions are included in plans submitted with this development
application
LI No
PART 3 — DEVELOPMENT DETAILS
Section 1 — Aspects of development
6.1) Provide details about the first development aspect
a) What is the type of development? (tick only one box)
M Material change of use LJ Reconfiguring a lot LJ Operational work LO Building work
b) What is the approval type? (tick only one box)
vw Development permit LJ Preliminary approval CJ Preliminary approval that includes a variation approval
c) What is the level of assessment?
L] Code assessment lV] Impact assessment (requires public notification)
d) Provide a brief description of the proposal (e.g. 6 unit apartment building defined as multi-unit dwelling, reconfiguration of 1 lot into 3
lots):
Proposed “Boutique Hotel” in conjunction with the existing Noosa Springs Golf and Spa Resort facilities to provide a
Resort Complex.
e) Relevant plans
Note: Relevant plans are required to be submitted for all aspects of this development application. For further information, see DA Forms guide:
Relevant plans.
lV] Relevant plans of the proposed development are attached to the development application.
6.2) Provide details about the second development aspect
a) What is the type of development? (tick only one box)
LJ Material change of use —_[_] Reconfiguring a lot LJ Operational work C1 Building work
b) What is the approval type? (tick only one box)
LJ Development permit LC Preliminary approval LJ Preliminary approval that includes a variation approval
c) What is the level of assessment?
L1 Code assessment LJ Impact assessment (requires public notification)
d) Provide a brief description of the proposal (e.g. 6 unit apartment building defined as multi-unit dwelling, reconfiguration of 1 lot into 3
lots):
e) Relevant plans
Note: Relevant plans are required to be submitted for all aspects of this development application. For further information, see DA Forms Guide:
Relevant plans.
LJ Relevant plans of the proposed development are attached to the development application
6.3) Additional aspects of development
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Additional aspects of development are relevant to this development application and the details for these aspects
that would be required under Part 3 Section 1 of this form have been attached to this development application
Not required
Section 2 – Further development details
7) Does the proposed development application involve any of the following?
Material change of use Yes – complete division 1 if assessable against a local planning instrument
Reconfiguring a lot Yes – complete division 2
Operational work Yes – complete division 3
Building work Yes – complete DA Form 2 – Building work details
Division 1 – Material change of use
Note: This division is only required to be completed if any part of the development application involves a material change of use assessable against a
local planning instrument.
8.1) Describe the proposed material change of use
Provide a general description of the Provide the planning scheme definition Number of dwelling Gross floor
proposed use (include each definition in a new row) units (if applicable) area (m2)
(if applicable)
Proposed “Boutique Hotel” development Resort Complex 106 suites 6862.00
Ancillary Café and Bar Food and Drink Outlet & Bar One 100.00
Tennis courts Outdoor Sport and Recreation Four N/A
Minor extension to existing clubhouse Club 105.00
8.2) Does the proposed use involve the use of existing buildings on the premises?
Yes
No
Division 2 – Reconfiguring a lot
Note: This division is only required to be completed if any part of the development application involves reconfiguring a lot.
9.1) What is the total number of existing lots making up the premises?
9.2) What is the nature of the lot reconfiguration? (tick all applicable boxes)
Subdivision (complete 10)) Dividing land into parts by agreement (complete 11))
Boundary realignment (complete 12)) Creating or changing an easement giving access to a lot
from a constructed road (complete 13))
10) Subdivision
10.1) For this development, how many lots are being created and what is the intended use of those lots:
Intended use of lots created Residential Commercial Industrial Other, please specify:
Number of lots created
10.2) Will the subdivision be staged?
Yes – provide additional details below
No
How many stages will the works include?
What stage(s) will this development application
apply to?
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LJ Additional aspects of development are relevant to this development application and the details for these aspects
that would be required under Part 3 Section 1 of this form have been attached to this development application
1 Not required
Section 2 — Further development details
7) Does the proposed development application involve any of the following?
Material change of use lV] Yes — complete division 1 if assessable against a local planning instrument
Reconfiguring a lot LJ Yes — complete division 2
Operational work LI Yes — complete division 3
Building work IVI Yes — complete DA Form 2— Building work details
Division 1 — Material change of use
Note: This division is only required to be completed if any part of the development application involves a material change of use assessable against a
local planning instrument.
8.1) Describe the proposed material change of use
Provide a general description of the Provide the planning scheme definition | Number of dwelling | Gross floor
proposed use (include each definition in a new row) units (if applicable) area (m?)
(if applicable)
Proposed “Boutique Hotel” development| Resort Complex 106 suites 6862.00
Ancillary Café and Bar Food and Drink Outlet & Bar One 100.00
Tennis courts Outdoor Sport and Recreation Four N/A
Minor extension to existing clubhouse Club 105.00
8.2) Does the proposed use involve the use of existing buildings on the premises?
M Yes
LI No
Division 2 — Reconfiguring a lot
Note: This division is only required to be completed if any part of the development application involves reconfiguring a lot.
9.1) What is the total number of existing lots making up the premises?
9.2) What is the nature of the lot reconfiguration? (tick all applicable boxes)
LJ Subdivision (complete 10)) C1 Dividing land into parts by agreement (complete 11))
LJ Boundary realignment (complete 12)) LJ Creating or changing an easement giving access to a lot
from a constructed road (complete 13))
10) Subdivision
10.1) For this development, how many lots are being created and what is the intended use of those lots:
Intended use of lots created Residential Commercial Industrial Other, please specify:
Number of lots created
10.2) Will the subdivision be staged?
CJ Yes — provide additional details below
LI No
How many stages will the works include?
What stage(s) will this development application
apply to?
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Version 1.3— 28 September 2020
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11) Dividing land into parts by agreement – how many parts are being created and what is the intended use of the
parts?
Intended use of parts created Residential Commercial Industrial Other, please specify:
Number of parts created
12) Boundary realignment
12.1) What are the current and proposed areas for each lot comprising the premises?
Current lot Proposed lot
Lot on plan description Area (m2) Lot on plan description Area (m2)
12.2) What is the reason for the boundary realignment?
13) What are the dimensions and nature of any existing easements being changed and/or any proposed easement?
(attach schedule if there are more than two easements)
Existing or Width (m) Length (m) Purpose of the easement? (e.g. Identify the land/lot(s)
proposed? pedestrian access) benefitted by the easement
Division 3 – Operational work
Note: This division is only required to be completed if any part of the development application involves operational work.
14.1) What is the nature of the operational work?
Road work Stormwater Water infrastructure
Drainage work Earthworks Sewage infrastructure
Landscaping Signage Clearing vegetation
Other – please specify:
14.2) Is the operational work necessary to facilitate the creation of new lots? (e.g. subdivision)
Yes – specify number of new lots:
No
14.3) What is the monetary value of the proposed operational work? (include GST, materials and labour)
$
PART 4 – ASSESSMENT MANAGER DETAILS
15) Identify the assessment manager(s) who will be assessing this development application
16) Has the local government agreed to apply a superseded planning scheme for this development application?
Yes – a copy of the decision notice is attached to this development application
The local government is taken to have agreed to the superseded planning scheme request – relevant documents
attached
No
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11) Dividing land into parts by agreement — how many parts are being created and what is the intended use of the
parts?
Intended use of parts created Residential Commercial Industrial Other, please specify:
Number of parts created
12) Boundary realignment
12.1) What are the current and proposed areas for each lot comprising the premises?
Current lot Proposed lot
Lot on plan description Area (m?) Lot on plan description Area (m?)
12.2) What is the reason for the boundary realignment?
13) What are the dimensions and nature of any existing easements being changed and/or any proposed easement?
(attach schedule if there are more than two easements)
Existing or Width (m) | Length (m) | Purpose of the easement? (e.g. Identify the land/lot(s)
proposed? pedestrian access) benefitted by the easement
Division 3 — Operational work
Note: This division is only required to be completed if any part of the development application involves operational work.
14.1) What is the nature of the operational work?
LJ Road work LD Stormwater LJ Water infrastructure
LJ Drainage work CJ Earthworks LJ Sewage infrastructure
CJ Landscaping UJ Signage LJ Clearing vegetation
LJ Other — please specify:
14.2) Is the operational work necessary to facilitate the creation of new lots? (e.g. subdivision)
LJ Yes — specify number of new lots:
LJ No
14.3) What is the monetary value of the proposed operational work? (include GST, materials and labour)
PART 4 —- ASSESSMENT MANAGER DETAILS
15) Identify the assessment manager(s) who will be assessing this development application
16) Has the local government agreed to apply a superseded planning scheme for this development application?
LJ Yes — a copy of the decision notice is attached to this development application
LJ The local government is taken to have agreed to the superseded planning scheme request — relevant documents
attached
1 No
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DA Form 1 — Development application details
Version 1.3— 28 September 2020
Page 6
PART 5 – REFERRAL DETAILS
17) Does this development application include any aspects that have any referral requirements?
Note: A development application will require referral if prescribed by the Planning Regulation 2017.
No, there are no referral requirements relevant to any development aspects identified in this development
application – proceed to Part 6
Matters requiring referral to the Chief Executive of the Planning Act 2016:
Clearing native vegetation
Contaminated land (unexploded ordnance)
Environmentally relevant activities (ERA) (only if the ERA has not been devolved to a local government)
Fisheries – aquaculture
Fisheries – declared fish habitat area
Fisheries – marine plants
Fisheries – waterway barrier works
Hazardous chemical facilities
Heritage places – Queensland heritage place (on or near a Queensland heritage place)
Infrastructure-related referrals – designated premises
Infrastructure-related referrals – state transport infrastructure
Infrastructure-related referrals – State transport corridor and future State transport corridor
Infrastructure-related referrals – State-controlled transport tunnels and future state-controlled transport tunnels
Infrastructure-related referrals – near a state-controlled road intersection
Koala habitat in SEQ region – interfering with koala habitat in koala habitat areas outside koala priority areas
Koala habitat in SEQ region – key resource areas
Ports – Brisbane core port land – near a State transport corridor or future State transport corridor
Ports – Brisbane core port land – environmentally relevant activity (ERA)
Ports – Brisbane core port land – tidal works or work in a coastal management district
Ports – Brisbane core port land – hazardous chemical facility
Ports – Brisbane core port land – taking or interfering with water
Ports – Brisbane core port land – referable dams
Ports – Brisbane core port land – fisheries
Ports – Land within Port of Brisbane’s port limits (below high-water mark)
SEQ development area
SEQ regional landscape and rural production area or SEQ rural living area – tourist activity or sport and
recreation activity
SEQ regional landscape and rural production area or SEQ rural living area – community activity
SEQ regional landscape and rural production area or SEQ rural living area – indoor recreation
SEQ regional landscape and rural production area or SEQ rural living area – urban activity
SEQ regional landscape and rural production area or SEQ rural living area – combined use
Tidal works or works in a coastal management district
Reconfiguring a lot in a coastal management district or for a canal
Erosion prone area in a coastal management district
Urban design
Water-related development – taking or interfering with water
Water-related development – removing quarry material (from a watercourse or lake)
Water-related development – referable dams
Water-related development –levees (category 3 levees only)
Wetland protection area
Matters requiring referral to the local government:
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PART 5 — REFERRAL DETAILS
17) Does this development application include any aspects that have any referral requirements?
Note: A development application will require referral if prescribed by the Planning Regulation 2017.
LINo, there are no referral requirements relevant to any development aspects identified in this development
application — proceed to Part 6
Matters requiring referral to the Chief Executive of the Planning Act 2016:
LJ Clearing native vegetation
LJ Contaminated land (unexploded ordnance)
CJ Environmentally relevant activities (ERA) (only if the ERA has not been devolved to a local government)
LJ Fisheries — aquaculture
LJ Fisheries — declared fish habitat area
CL Fisheries — marine plants
LJ Fisheries — waterway barrier works
LJ Hazardous chemical facilities
LJ Heritage places — Queensland heritage place (on or near a Queensland heritage place)
CJ Infrastructure-related referrals — designated premises
M1 Infrastructure-related referrals — state transport infrastructure
LJ Infrastructure-related referrals — State transport corridor and future State transport corridor
CJ Infrastructure-related referrals — State-controlled transport tunnels and future state-controlled transport tunnels
CJ Infrastructure-related referrals — near a state-controlled road intersection
M1 Koala habitat in SEQ region — interfering with koala habitat in koala habitat areas outside koala priority areas
CL Koala habitat in SEQ region — key resource areas
LJ Ports — Brisbane core port land — near a State transport corridor or future State transport corridor
LJ Ports — Brisbane core port land — environmentally relevant activity (ERA)
LJ Ports — Brisbane core port land — tidal works or work in a coastal management district
LJ Ports — Brisbane core port land — hazardous chemical facility
LJ Ports — Brisbane core port land — taking or interfering with water
CJ Ports — Brisbane core port land — referable dams
LJ Ports — Brisbane core port land — fisheries
CJ Ports — Land within Port of Brisbane’s port limits (below high-water mark)
LJ SEQ development area
LJ SEQ regional landscape and rural production area or SEQ rural living area — tourist activity or sport and
recreation activity
LJ SEQ regional landscape and rural production area or SEQ rural living area — community activity
LJ SEQ regional landscape and rural production area or SEQ rural living area — indoor recreation
LJ SEQ regional landscape and rural production area or SEQ rural living area — urban activity
LJ SEQ regional landscape and rural production area or SEQ rural living area — combined use
C1 Tidal works or works in a coastal management district
LJ Reconfiguring a lot in a coastal management district or for a canal
CJ Erosion prone area in a coastal management district
LJ Urban design
CL Water-related development — taking or interfering with water
LJ Water-related development — removing quarry material (from a watercourse or lake)
CL Water-related development — referable dams
LJ Water-related development —levees (category 3 levees only)
LJ Wetland protection area
Matters requiring referral to the local government:
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Airport land
Environmentally relevant activities (ERA) (only if the ERA has been devolved to local government)
Heritage places – Local heritage places
Matters requiring referral to the Chief Executive of the distribution entity or transmission entity:
Infrastructure-related referrals – Electricity infrastructure
Matters requiring referral to:
• The Chief Executive of the holder of the licence, if not an individual
• The holder of the licence, if the holder of the licence is an individual
Infrastructure-related referrals – Oil and gas infrastructure
Matters requiring referral to the Brisbane City Council:
Ports – Brisbane core port land
Matters requiring referral to the Minister responsible for administering the Transport Infrastructure Act 1994:
Ports – Brisbane core port land (where inconsistent with the Brisbane port LUP for transport reasons)
Ports – Strategic port land
Matters requiring referral to the relevant port operator, if applicant is not port operator:
Ports – Land within Port of Brisbane’s port limits (below high-water mark)
Matters requiring referral to the Chief Executive of the relevant port authority:
Ports – Land within limits of another port (below high-water mark)
Matters requiring referral to the Gold Coast Waterways Authority:
Tidal works or work in a coastal management district (in Gold Coast waters)
Matters requiring referral to the Queensland Fire and Emergency Service:
Tidal works or work in a coastal management district (involving a marina (more than six vessel berths))
18) Has any referral agency provided a referral response for this development application?
Yes – referral response(s) received and listed below are attached to this development application
No
Referral requirement Referral agency Date of referral response
Identify and describe any changes made to the proposed development application that was the subject of the
referral response and this development application, or include details in a schedule to this development application
(if applicable).
PART 6 – INFORMATION REQUEST
19) Information request under Part 3 of the DA Rules
I agree to receive an information request if determined necessary for this development application
I do not agree to accept an information request for this development application
Note: By not agreeing to accept an information request I, the applicant, acknowledge:
• that this development application will be assessed and decided based on the information provided when making this development
application and the assessment manager and any referral agencies relevant to the development application are not obligated under the DA
Rules to accept any additional information provided by the applicant for the development 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.
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CO Airport land
CJ Environmentally relevant activities (ERA) (only if the ERA has been devolved to local government)
LJ Heritage places — Local heritage places
Matters requiring referral to the Chief Executive of the distribution entity or transmission entity:
M1 Infrastructure-related referrals — Electricity infrastructure
Matters requiring referral to:
e The Chief Executive of the holder of the licence, if not an individual
e The holder of the licence, if the holder of the licence is an individual
LJ Infrastructure-related referrals — Oil and gas infrastructure
Matters requiring referral to the Brisbane City Council:
LJ Ports — Brisbane core port land
Matters requiring referral to the Minister responsible for administering the Transport Infrastructure Act 1994:
LJ Ports — Brisbane core port land (where inconsistent with the Brisbane port LUP for transport reasons)
C1 Ports — Strategic port land
Matters requiring referral to the relevant port operator, if applicant is not port operator:
C1 Ports — Land within Port of Brisbane’s port limits (below high-water mark)
Matters requiring referral to the Chief Executive of the relevant port authority:
C1 Ports — Land within limits of another port (below high-water mark)
Matters requiring referral to the Gold Coast Waterways Authority:
LJ Tidal works or work in a coastal management district (in Gold Coast waters)
Matters requiring referral to the Queensland Fire and Emergency Service:
LJ Tidal works or work in a coastal management district (involving a marina (more than six vessel berths))
18) Has any referral agency provided a referral response for this development applicati
LJ Yes — referral response(s) received and listed below are attached to this development application
1 No
Referral requirement Referral agency Date of referral response
Identify and describe any changes made to the proposed development application that was the subject of the
referral response and this development application, or include details in a schedule to this development application
(if applicable).
PART 6 — INFORMATION REQUEST
19) Information request under Part 3 of the DA Rules
M1 agree to receive an information request if determined necessary for this development application
LJ | do not agree to accept an information request for this development application
Note: By not agreeing to accept an information request I, the applicant, acknowledge:
e that this development application will be assessed and decided based on the information provided when making this development
application and the assessment manager and any referral agencies relevant to the development application are not obligated under the DA
Rules to accept any additional information provided by the applicant for the development application unless agreed to by the relevant
parties
e 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.
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PART 7 – FURTHER DETAILS
20) Are there any associated development applications or current approvals? (e.g. a preliminary approval)
Yes – provide details below or include details in a schedule to this development application
No
List of approval/development Reference number Date Assessment
application references manager
Approval Change to Approval 17380
11/5/2006
Noosa Shire
Development application DA
Approval 21677 DA 15/6/2001
Noosa Shire
Development application
21) Has the portable long service leave levy been paid? (only applicable to development applications involving building work or
operational work)
Yes – a copy of the receipted QLeave form is attached to this development application
No – I, the applicant will provide evidence that the portable long service leave levy has been paid before the
assessment manager decides the development application. I acknowledge that the assessment manager may
give a development approval only if I provide evidence that the portable long service leave levy has been paid
Not applicable (e.g. building and construction work is less than $150,000 excluding GST)
Amount paid Date paid (dd/mm/yy) QLeave levy number (A, B or E)
$
22) Is this development application in response to a show cause notice or required as a result of an enforcement
notice?
Yes – show cause or enforcement notice is attached
No
23) Further legislative requirements
Environmentally relevant activities
23.1) Is this development application also taken to be an application for an environmental authority for an
Environmentally Relevant Activity (ERA) under section 115 of the Environmental Protection Act 1994?
Yes – the required attachment (form ESR/2015/1791) for an application for an environmental authority
accompanies this development application, and details are provided in the table below
No
Note: Application for an environmental authority can be found by searching “ESR/2015/1791” as a search term at www.qld.gov.au. An ERA
requires an environmental authority to operate. See www.business.qld.gov.au for further information.
Proposed ERA number: Proposed ERA threshold:
Proposed ERA name:
Multiple ERAs are applicable to this development application and the details have been attached in a schedule to
this development application.
Hazardous chemical facilities
23.2) Is this development application for a hazardous chemical facility?
Yes – Form 69: Notification of a facility exceeding 10% of schedule 15 threshold is attached to this development
application
No
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PART 7 — FURTHER DETAILS
20) Are there any associated development applications or current approvals? (e.g. a preliminary approval)
M1 Yes — provide details below or include details in a schedule to this development application
LI No
List of approval/development Reference number Date Assessment
application references manager
Noosa Shire
Vv] Approval prange to Approval 17380 11/5/2006
LJ Development application
Noosa Shire
M1 Approval 21677 DA 15/6/2001
LJ Development application
21) Has the portable long service leave levy been paid? (only applicable to development applications involving building work or
operational work)
LJ Yes — a copy of the receipted QLeave form is attached to this development application
1 No- |, the applicant will provide evidence that the portable long service leave levy has been paid before the
assessment manager decides the development application. | acknowledge that the assessment manager may
give a development approval only if | provide evidence that the portable long service leave levy has been paid
LJ Not applicable (e.g. building and construction work is less than $150,000 excluding GST)
Amount paid Date paid (dd/mm/yy) QLeave levy number (A, B or E)
$
22) Is this development application in response to a show cause notice or required as a result of an enforcement
notice?
LJ Yes — show cause or enforcement notice is attached
VI No
23) Further legislative requirements
Environmentally relevant acti gy
23.1) Is this development application also taken to be an application for an environmental authority for an
Environmentally Relevant Activity (ERA) under section 115 of the Environmental Protection Act 1994?
LJ Yes — the required attachment (form ESR/2015/1791) for an application for an environmental authority
accompanies this development application, and details are provided in the table below
1 No
Note: Application for an environmental authority can be found by searching “ESR/2015/1791” as a search term at www.qld.gov.au. An ERA
requires an environmental authority to operate. See www.business.qld.gov.au for further information.
Proposed ERA number: Proposed ERA threshold:
Proposed ERA name:
LJ Multiple ERAs are applicable to this development application and the details have been attached in a schedule to
this development application.
Hazardous chemical facilities
23.2) Is this development application for a hazardous chemical facility?
LJ Yes — Form 69: Notification of a facility exceeding 10% of schedule 15 threshold is attached to this development
application
I No
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Note: See www.business.qld.gov.au for further information about hazardous chemical notifications.
Clearing native vegetation
23.3) Does this development application involve clearing native vegetation that requires written confirmation that
the chief executive of the Vegetation Management Act 1999 is satisfied the clearing is for a relevant purpose under
section 22A of the Vegetation Management Act 1999?
Yes – this development application includes written confirmation from the chief executive of the Vegetation
Management Act 1999 (s22A determination)
No
Note: 1. Where a development application for operational work or material change of use requires a s22A determination and this is not included,
the development application is prohibited development.
2. See https://www.qld.gov.au/environment/land/vegetation/applying for further information on how to obtain a s22A determination.
Environmental offsets
23.4) Is this development application taken to be a prescribed activity that may have a significant residual impact on
a prescribed environmental matter under the Environmental Offsets Act 2014?
Yes – I acknowledge that an environmental offset must be provided for any prescribed activity assessed as
having a significant residual impact on a prescribed environmental matter
No
Note: The environmental offset section of the Queensland Government’s website can be accessed at www.qld.gov.au for further information on
environmental offsets.
Koala habitat in SEQ Region
23.5) Does this development application involve a material change of use, reconfiguring a lot or operational work
which is assessable development under Schedule 10, Part 10 of the Planning Regulation 2017?
Yes – the development application involves premises in the koala habitat area in the koala priority area
Yes – the development application involves premises in the koala habitat area outside the koala priority area
No
Note: If a koala habitat area determination has been obtained for this premises and is current over the land, it should be provided as part of this
development application. See koala habitat area guidance materials at www.des.qld.gov.au for further information.
Water resources
23.6) Does this development application involve taking or interfering with underground water through an
artesian or subartesian bore, taking or interfering with water in a watercourse, lake or spring, or taking
overland flow water under the Water Act 2000?
Yes – the relevant template is completed and attached to this development application and I acknowledge that a
relevant authorisation or licence under the Water Act 2000 may be required prior to commencing development
No
Note: Contact the Department of Natural Resources, Mines and Energy at www.dnrme.qld.gov.au for further information.
DA templates are available from https://planning.dsdmip.qld.gov.au/. If the development application involves:
• Taking or interfering with underground water through an artesian or subartesian bore: complete DA Form 1 Template 1
• Taking or interfering with water in a watercourse, lake or spring: complete DA Form1 Template 2
• Taking overland flow water: complete DA Form 1 Template 3.
Waterway barrier works
23.7) Does this application involve waterway barrier works?
Yes – the relevant template is completed and attached to this development application
No
DA templates are available from https://planning.dsdmip.qld.gov.au/. For a development application involving waterway barrier works, complete
DA Form 1 Template 4.
Marine activities
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Note: See www.business.qld.gov.au for further information about hazardous chemical notifications.
Clearing native vegetation
23.3) Does this development application involve clearing native vegetation that requires written confirmation that
the chief executive of the Vegetation Management Act 1999 is satisfied the clearing is for a relevant purpose under
section 22A of the Vegetation Management Act 1999?
LD Yes — this development application includes written confirmation from the chief executive of the Vegetation
Management Act 1999 (s22A determination)
1 No
Note: 1. Where a development application for operational work or material change of use requires a s22A determination and this is not included,
the development application is prohibited development.
2. See https://www.qid.gov.au/environment/land/vegetation/applying for further information on how to obtain a s22A determination.
Environmental offsets
23.4) Is this development application taken to be a prescribed activity that may have a significant residual impact on
a prescribed environmental matter under the Environmental Offsets Act 2014?
M1 Yes -| acknowledge that an environmental offset must be provided for any prescribed activity assessed as
having a significant residual impact on a prescribed environmental matter
LI No
Note: The environmental offset section of the Queensland Government's website can be accessed at www.qld.gov.au for further information on
environmental offsets.
Koala habitat in SEQ Region
23.5) Does this development application involve a material change of use, reconfiguring a lot or operational work
which is assessable development under Schedule 10, Part 10 of the Planning Regulation 2017?
LJ Yes — the development application involves premises in the koala habitat area in the koala priority area
1 Yes — the development application involves premises in the koala habitat area outside the koala priority area
LI No
Note: If a koala habitat area determination has been obtained for this premises and is current over the land, it should be provided as part of this
development application. See koala habitat area guidance materials at www.des.qid.gov.au for further information.
AEN Te ETT Ce
23.6) Does this development application involve taking or interfering with underground water through an
artesian or subartesian bore, taking or interfering with water in a watercourse, lake or spring, or taking
overland flow water under the Water Act 2000?
LJ Yes — the relevant template is completed and attached to this development application and | acknowledge that a
relevant authorisation or licence under the Water Act 2000 may be required prior to commencing development
MI No
Note: Contact the Department of Natural Resources, Mines and Energy at www.dnrme.qid.gov.au for further information.
DA templates are available from https.//planning.dsdmip.qlid.gov.au/. If the development application involves:
e — Taking or interfering with underground water through an artesian or subartesian bore: complete DA Form 1 Template 1
e Taking or interfering with water in a watercourse, lake or spring: complete DA Form1 Template 2
e Taking overland flow water: complete DA Form 1 Template 3.
Waterway barrier works
23.7) Does this application involve waterway barrier works?
LJ Yes — the relevant template is completed and attached to this development application
1 No
DA templates are available from https.//planning.dsdmip.qld.gov.au/. For a development application involving waterway barrier works, complete
DA Form 1 Template 4.
Marine activities
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23.8) Does this development application involve aquaculture, works within a declared fish habitat area or
removal, disturbance or destruction of marine plants?
Yes – an associated resource allocation authority is attached to this development application, if required under
the Fisheries Act 1994
No
Note: See guidance materials at www.daf.qld.gov.au for further information.
Quarry materials from a watercourse or lake
23.9) Does this development application involve the removal of quarry materials from a watercourse or lake
under the Water Act 2000?
Yes – I acknowledge that a quarry material allocation notice must be obtained prior to commencing development
No
Note: Contact the Department of Natural Resources, Mines and Energy at www.dnrme.qld.gov.au and www.business.qld.gov.au for further
information.
Quarry materials from land under tidal waters
23.10) Does this development application involve the removal of quarry materials from land under tidal water
under the Coastal Protection and Management Act 1995?
Yes – I acknowledge that a quarry material allocation notice must be obtained prior to commencing development
No
Note: Contact the Department of Environment and Science at www.des.qld.gov.au for further information.
Referable dams
23.11) Does this development application involve a referable dam required to be failure impact assessed under
section 343 of the Water Supply (Safety and Reliability) Act 2008 (the Water Supply Act)?
Yes – the ‘Notice Accepting a Failure Impact Assessment’ from the chief executive administering the Water
Supply Act is attached to this development application
No
Note: See guidance materials at www.dnrme.qld.gov.au for further information.
Tidal work or development within a coastal management district
23.12) Does this development application involve tidal work or development in a coastal management district?
Yes – the following is included with this development application:
Evidence the proposal meets the code for assessable development that is prescribed tidal work (only required
if application involves prescribed tidal work)
A certificate of title
No
Note: See guidance materials at www.des.qld.gov.au for further information.
Queensland and local heritage places
23.13) Does this development application propose development on or adjoining a place entered in the Queensland
heritage register or on a place entered in a local government’s Local Heritage Register?
Yes – details of the heritage place are provided in the table below
No
Note: See guidance materials at www.des.qld.gov.au for information requirements regarding development of Queensland heritage places.
Name of the heritage place: Place ID:
Brothels
23.14) Does this development application involve a material change of use for a brothel?
Yes – this development application demonstrates how the proposal meets the code for a development
application for a brothel under Schedule 3 of the Prostitution Regulation 2014
No
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23.8) Does this development application involve aquaculture, works within a declared fish habitat area or
removal, disturbance or destruction of marine plants?
LJ Yes — an associated resource allocation authority is attached to this development application, if required under
the Fisheries Act 1994
MI No
Note: See guidance materials at www.daf.gld.gov.au for further information.
Quarry materials from a watercourse or lake
23.9) Does this development application involve the removal of quarry materials from a watercourse or lake
under the Water Act 2000?
C1 Yes — | acknowledge that a quarry material allocation notice must be obtained prior to commencing development
1 No
Note: Contact the Department of Natural Resources, Mines and Energy at www.dnrme.qgid.gov.au and www.business.qid.gov.au for further
information.
Quarry materials from land under tidal waters
23.10) Does this development application involve the removal of quarry materials from land under tidal water
under the Coastal Protection and Management Act 1995?
LJ Yes — | acknowledge that a quarry material allocation notice must be obtained prior to commencing development
IVINo
Note: Contact the Department of Environment and Science at www.des.qid.gov.au for further information.
Referable dams
23.11) Does this development application involve a referable dam required to be failure impact assessed under
section 343 of the Water Supply (Safety and Reliability) Act 2008 (the Water Supply Act)?
LJ Yes — the ‘Notice Accepting a Failure Impact Assessment’ from the chief executive administering the Water
Supply Act is attached to this development application
MI No
Note: See guidance materials at www.dnrme.gid.gov.au for further information.
Tidal work or development within a coastal management district
23.12) Does this development application involve tidal work or development in a coastal management district?
LJ Yes — the following is included with this development application:
L Evidence the proposal meets the code for assessable development that is prescribed tidal work (only required
if application involves prescribed tidal work)
C1 Acertificate of title
VI No
Note: See guidance materials at www.des.qid.gov.au for further information.
Queensland and local heritage places
23.13) Does this development application propose development on or adjoining a place entered in the Queensland
heritage register or on a place entered in a local government’s Local Heritage Register?
LJ Yes — details of the heritage place are provided in the table below
1 No
Note: See guidance materials at www.des.qld.gov.au for information requirements regarding development of Queensland heritage places.
Name of the heritage place: Place ID:
Brothels
23.14) Does this development application involve a material change of use for a brothel?
LD Yes — this development application demonstrates how the proposal meets the code for a development
application for a brothel under Schedule 3 of the Prostitution Regulation 2014
1 No
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Decision under section 62 of the Transport Infrastructure Act 1994
23.15) Does this development application involve new or changed access to a state-controlled road?
Yes – this application will be taken to be an application for a decision under section 62 of the Transport
Infrastructure Act 1994 (subject to the conditions in section 75 of the Transport Infrastructure Act 1994 being
satisfied)
No
Walkable neighbourhoods assessment benchmarks under Schedule 12A of the Planning Regulation
23.16) Does this development application involve reconfiguring a lot into 2 or more lots in certain residential zones
(except rural residential zones), where at least one road is created or extended?
Yes – Schedule 12A is applicable to the development application and the assessment benchmarks contained in
schedule 12A have been considered
No
Note: See guidance materials at www.planning.dsdmip.qld.gov.au for further information.
PART 8 – CHECKLIST AND APPLICANT DECLARATION
24) Development application checklist
I have identified the assessment manager in question 15 and all relevant referral
requirement(s) in question 17 Yes
Note: See the Planning Regulation 2017 for referral requirements
If building work is associated with the proposed development, Parts 4 to 6 of DA Form 2 – Yes
Building work details have been completed and attached to this development application
Not applicable
Supporting information addressing any applicable assessment benchmarks is with the
development application
Note: This is a mandatory requirement and includes any relevant templates under question 23, a planning report
and any technical reports required by the relevant categorising instruments (e.g. local government planning
Yes
schemes, State Planning Policy, State Development Assessment Provisions). For further information, see DA
Forms Guide: Planning Report Template.
Relevant plans of the development are attached to this development application
Note: Relevant plans are required to be submitted for all aspects of this development application. For further Yes
information, see DA Forms Guide: Relevant plans.
The portable long service leave levy for QLeave has been paid, or will be paid before a Yes
development permit is issued (see 21)
Not applicable
25) Applicant declaration
By making this development application, I declare that all information in this development application is true and
correct
Where an email address is provided in Part 1 of this form, I consent to receive future electronic communications
from the assessment manager and any referral agency for the development 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 assessment manager and/or chosen
assessment manager, any relevant referral agency and/or building certifier (including any professional advisers
which may be engaged by those entities) while processing, assessing and deciding the development application.
All information relating to this development 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:
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Decision under section 62 of the Transport Infrastructure Act 1994
23.15) Does this development application involve new or changed access to a state-controlled road?
LJ Yes — this application will be taken to be an application for a decision under section 62 of the Transport
Infrastructure Act 1994 (subject to the conditions in section 75 of the Transport Infrastructure Act 1994 being
satisfied)
1 No
Walkable neighbourhoods assessment benchmarks under Schedule 12A of the Planning Requlation
23.16) Does this development application involve reconfiguring a lot into 2 or more lots in certain residential zones
(except rural residential zones), where at least one road is created or extended?
LJ Yes — Schedule 12A is applicable to the development application and the assessment benchmarks contained in
schedule 12A have been considered
1 No
Note: See guidance materials at www.planning.dsdmip.gqid.gov.au for further information.
PART 8 — CHECKLIST AND APPLICANT DECLARATION
24) Development application checklist
| have identified the assessment manager in question 15 and all relevant referral
requirement(s) in question 17 M1 Yes
Note: See the Planning Regulation 2017 for referral requirements
If building work is associated with the proposed development, Parts 4 to 6 of DAForm2—- Wf ves
Building work details have been completed and attached to this development application
LJ Not applicable
Supporting information addressing any applicable assessment benchmarks is with the
development application
Note: This is a mandatory requirement and includes any relevant templates under question 23, a planning report vw Yes
and any technical reports required by the relevant categorising instruments (e.g. local government planning
schemes, State Planning Policy, State Development Assessment Provisions). For further information, see DA
Forms Guide: Planning Report Template.
Relevant plans of the development are attached to this development application
Note: Relevant plans are required to be submitted for all aspects of this development application. For further vi Yes
information, see DA Forms Guide: Relevant plans.
The portable long service leave levy for QLeave has been paid, or will be paid before a LC Yes
development permit is issued (see 27) M Not applicable
25) Applicant declaration
vi By making this development application, | declare that all information in this development application is true and
correct
lV] Where an email address is provided in Part 1 of this form, | consent to receive future electronic communications
from the assessment manager and any referral agency for the development 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 assessment manager and/or chosen
assessment manager, any relevant referral agency and/or building certifier (including any professional advisers
which may be engaged by those entities) while processing, assessing and deciding the development application.
All information relating to this development 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:
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Page 12
• 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.
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e 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
e required by other legislation (including the Right to Information Act 2009); or
e 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.
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PART 9 – FOR COMPLETION OF THE ASSESSMENT MANAGER – FOR OFFICE
USE ONLY
Date received: Reference number(s):
Notification of engagement of alternative assessment manager
Prescribed assessment manager
Name of chosen assessment manager
Date chosen assessment manager engaged
Contact number of chosen assessment manager
Relevant licence number(s) of chosen assessment
manager
QLeave notification and payment
Note: For completion by assessment manager if applicable
Description of the work
QLeave project number
Amount paid ($) Date paid (dd/mm/yy)
Date receipted form sighted by assessment manager
Name of officer who sighted the form
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PART 9 — FOR COMPLETION OF THE ASSESSMENT MANAGER — FOR OFFICE
USE ONLY
Date received: [sid Reference number(s): |
Notification of engagement of alternative assessment manager
Prescribed assessment manager
Name of chosen assessment manager
Date chosen assessment manager engaged
Contact number of chosen assessment manager
Relevant licence number(s) of chosen assessment
manager
Description of the work
QLeave notification and payment
Note: For completion by assessment manager if applicable
QLeave project number
Amount paid ($) |
Date paid (dd/mm/yy)
Date receipted form sighted by assessment manager
Name of officer who sighted the form
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