1. Application Form

Change application form
Planning Act Form 5 (version 1.1 effective 22 JUNE 2018) 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)                   Rubicon Design & Construct C/- Planit Consulting Pty Ltd
Contact name (only applicable for companies)                          Brendan Ferris
Postal address (P.O. Box or street address)                           PO Box 206
Suburb                                                                Nobby Beach
State                                                                 QLD
Postcode                                                              4218
Country                                                               Australia
Email address (non-mandatory)                                         [email protected]
Mobile number (non-mandatory)
Applicant’s reference number(s) (if applicable)                       J6130

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
     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
   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
         -                  5                    Memorial Avenue                                       Tewantin
a)
         Postcode           Lot No.              Plan Type and Number (e.g. RP, SP)                    Local Government Area(s)
                            10                   SP273411                                              Noosa
         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)

         Unit No.           Street No.           Street Name and Type                                  Suburb

c)       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. Only one set of coordinates is required for this part.
   Coordinates of premises by longitude and latitude
Longitude(s)             Latitude(s)               Datum                                             Local Government Area(s) (if applicable)