CCE03122012_0000 · OPW13/0059

 

 

 

 

 

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Privacy—the information collected in this form will be used by the Department of Infrastructure and Pla
accordance with the processing and. assessment of your application. Your personal details will not be d
outside of the IDAS process, except where required by legislation (including the Right to /nformation Act 2009) or as required
by Parliament. This information may be stored in a departmental database. The information collected wi
required by the Public Records Act 2002.

Nning (DIP) in
sclosed for a purpose

Il be retained as

 

OFFICE USE ONLY

 

Date received

 

 

 

NOTIFICATION OF ENGAGEMENT OF A PRIVATE CERTIFIER

 

To

 

 

 

Reference numbers

 

 

 

Council. | have been engaged as the private certifier for the b
to in this application

uilding work referred

 

Date of engagement

Name

BSA Certification license number

Building
classification/s

 

 

 

 

QLEAVE NOTIFICATION AND PAYMENT (for completion by assessment manager or private certifier if applicable)

 

Description of the work

QLeave Project
Number

Amount paid

($)

Date receipted
form sighted by
assessment
manager

Date paid

Name of officer who
sighted the form

 

 

 

 

 

 

 

The Sustainable Planning Act z009 (SPA) is administered by the Department of Infrastructure and Plan
all other required application materials should be sent to your assessment manager and any referral a

ining. This form and
igencies.

 

Application detail
Version 1.018 D

ism/DAS form 1
lecember 2009