DA Form 5

​



    12) Further details
    ☐ Part 7 of DA Form 1 – Development application details is completed as if the change application was a
      development application and is provided with this application.


PART 7 – CHECKLIST AND APPLICANT DECLARATION

    13) Change application checklist
    I have identified the:
     ●​ responsible entity in 4); and
     ●​ for a minor change, any affected entities; and                                                                     ☒ Yes
     ●​ for an other change all relevant referral requirement(s) in 10)
    Note: See the Planning Regulation 2017 for referral requirements
    For an other change application, the relevant sections of DA Form 1 – Development                                      ☐ Yes
    application details have been completed and is attached to this application                                            ☒ Not applicable
    For an other change application, where building work is associated with the change                                     ☐ Yes
    application, the relevant sections of DA Form 2 – Building work details have been
    completed and is attached to this application                                                                          ☒ Not applicable
    Supporting information addressing any applicable assessment benchmarks is attached to
    this application
    Note: This includes any templates provided under 23.6 and 23.7 of DA Form 1 – Development application details          ☒ Yes
    that are relevant as a result of the change application, a planning report and any technical reports required by the
    relevant categorising instrument(s) (e.g. the local government planning scheme, State Planning Policy, State
    Development Assessment Provisions). For further information, see DA Forms Guide: Planning report template.
    Relevant plans of the development are attached to this development application
    Note: Relevant plans are required to be submitted for all relevant aspects of this change application. For further     ☒ Yes
    information, see DA Forms Guide: Relevant plans.


    14) Applicant declaration
    ☒ By making this change application, I declare that all information in this change application is true and correct.
    ☒ Where an email address is provided in Part 1 of this form, I consent to receive future electronic communications
      from the responsible entity and any relevant affected entity or referral agency for the change application where
      written information is required or permitted pursuant to sections 11 and 12 of the Electronic Transactions
      Act 2001.
    Note: It is unlawful 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:
    ●​ 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 Act 2016
          and Planning Regulation 2017; or
    ●​ required by other legislation (including the Right to Information Act 2009); or
    ●​ otherwise required by law.
    This information may be stored in relevant databases. The information collected will be retained as required by the
    Public Records Act 2002.




                                                                                                                                                  Page 4
                                                                                                            Planning Act Form 5 - Change application form
​                                                                                              ​                                          ​       Version
                                                                                                                                   1.2 — 7 February 2020