Change Application Form Little Sister

                                                                    Department of lnfrastructure, Local 6overnment and Planning


 information is required or permitted pursuant to sections 11 and 12 of the Electronic Transactions Act 2041 .
 Nofe; /f r.s unlav,iul to intentionally provide false or misleading information.
 Privacy - Personal information collected in this form will be used by the responsible entity and/or chosen assessment
 manager, any relevant affected entity or referral agency and/or building certifier (including any professional advisers which
 may be engaged by those entities) while processing, assessing and deciding the change application.
 All information relating to this change 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:
 o    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 Ad 2A16 and Planning
     Regulation 2417; or
 . required by other legislation (including the Rlghf to lnformatian Act 240$; or
 o othenvise required by law.
 This information may be stored in relevant databases" The information collected will be retained as required by the Public
 Records Act 2402.


PART 7 - FOR CFFICE USE ONLY

 Date received:                            Reference number(s):




 Description of the work
 Qleave project number
 Amount paid ($)


 Date receipted form sighted by assessment manager
 Name of officer who sighted the form

The Planning Act 2016,hhe Planning Regulation 2017 and the DA Rules are administered by the Department of
Infrastructure, Local Government and Planning. This form and all other required change application materials should be
sent to the responsible entity.




                                                                                                                               Page 4
                                                                                       Planning Act Form 5 - Change application form
                                                                                                            Version '1 .0-3 July 2017