20210105 - Form 5- Change Application Form

PART 8 – FOR COMPLETION OF THE ASSESSMENT MANAGER – FOR OFFICE
USE ONLY

 Date received:        01/04/2021                 Reference number(s):   20210105

 QLeave notification and payment
 Note: For completion by assessment manager if applicable
 Description of the work                                         PROPOSED NEW GARAGE & FIRE SAFE BLOCK
                                                                 WALL PARAPET
 QLeave project number                                           N/A
 Amount paid ($)                    N/A                          Date paid (dd/mm/yy)            N/A
 Date receipted form sighted by assessment manager               N/A
 Name of officer who sighted the form                            N/A




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