Authority to amend IDAS forms - OPW14/0197

Page 2

NOTIPCATONGND PRCMENT au —Susereaucruamer |
UAT

Form BCI 10 v4 Effective 01-Jan-2010

  

THIS FORM CAN ALSO BE COMPLETED AND PAID ONLINE

 

 

 

 

 

 

 

 

ABN, 69506 619 186 PLEASE DO NOT USE STAPLES ON THIS FORM. (*) denotes mandatory |__—_B361981
(PART1 | PAYERDETAILS I
Please use BLACK INK and print within boxes using Levy Payer Customer No Payer Legal Name ABN (if applicable)
BLOCK LETTERS.
fETX[A M P LIE]
Payer jal Name *

 

 

 

 

 

 

 

 

 

 

 

Trading Name (it licable)

 

 

 

 

 

 

 

 

 

 

 

 

 

nit Number Street Number Street Name *
Suburb* State Code
Contact Person Contact Daytime Phone No. (include area code) *

 

 

 

 

 

 

 

 

 

 

 

 

 

PART 2 | PROJECT DETAILS 2 oe — 7 7]
Project Description *

‘ot No. (H applicable) Plan No. (if applicable)

Street Number Name *

 

 

 

 

 

uburb * State L Code

Your Job No. or Reference No. (if applicable) Estimate Your Start Date * Expected Completion Date *

 

 

 

 

Project Owner (who is the work being done for) *

 

 

Certifier Business Name *

 

 

 

 

one No. (include area code)

 

 

Principal Contractor Legal Name (If Inted, otherwise write UNKNOWN) *

 

—— |__| __|___|_____|__
SF

 

 

YELLOW - PRIVATE CERTIFIER/LOCAL GOVERNMENT (COUNCIL) COPY

 

 

 

 

 

 

 

 

 

 

of

 

Principal Contractor ABN * Principal Contractor Phone No. (Include area code) * er Builder No. (if applicable)
O|B
'PART 3 | LEVY /FEE PAYMENT AL: énounTs aRE 706i Be SHOWN TC THE NEAREST WHOLE DOLLAR 50 CENTS OR BELOW ROUND DOWN -

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

51 CENTS OR ABOVE ROUND UP TO NEAREST DOLLAR
Notification for Building and Construction work more than $80,000 ( Inc. est) > A $ : : 3 .

Total Cost of Work (inc. GST)

Exempted Cost of Work (documentation may be requested) B $ A 3 | : 7
Leviable Cost of Work (C = A - B} L_j_|__j
Levies and Fee Payable (GST is not payable on the Levies or c $ | |

Fee) D=C x 0.525% 7

Cross this box if you are applying for instalments. Building and D $
ants DE work is over $5M and completion will take more than one year.

4|DECLARATION sa ASNOFFICEDISE ONLY

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