Revised DA Form 1 · OPW22/0093

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                                   John Dunn
 Name of chosen assessment manager                               John Dunn
 Date chosen assessment manager engaged                          29/03/2022
 Contact number of chosen assessment manager                     1300 596 371
 Relevant licence number(s) of chosen assessment                 A621704
 manager

 QLeave notification and payment
 Note: For completion by assessment manager if applicable
 Description of the work                                         Double Carport, Rear Alfresco area & Shed
 QLeave project number
 Amount paid ($)                    $                            Date paid (dd/mm/yy)
 Date receipted form sighted by assessment manager
 Name of officer who sighted the form                            John Dunn




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                                                                                        DA Form 1 – Development application details
                                                                                                 Version 1.3— 28 September 2020