001A666E.001

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 ._ “INTEGRATED PLANNING ACT 1997                                                                                 Part A, Version 3.1, 3 March 2008
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     INOTE: Answer all questions untess directed to go to a particular question. Refer to the end of the form for advice on how to complete this form.
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     individual applicant/Contact person (If there is more than one applicant, provide additional applicant details on an attachment to this form)
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     1.   Identify the premises by completing Table A, or Table B and/or Table C (ensure adequate information is given to identify the premises)
     Table A _ If the application is for a mobile and temporary Environmentally Relevant Activity (ERA), complete Table A only. Then go to Q2.
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@ TableB       Street address for the premises (lick applicable box/es below and insert property description in the table. Identify each jot in a separate row.)
            (i). [) Street address / lot on plan for the premises (Appropriate for most applications including building applications); OF
            (ii) [_] Street address Alot on plan for the land adjoining or adjacent to the premises (Appropriate for development in water e.g. jetty,
                    pontoon etc) (Note: Loton plan details may be obtained from title documents, a ‘Rate’ notice, or from the local government.) ‘
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      AND/OR
      Table C  Coordinates and/or a map of the premises (Appropriate for development in remote areas, over part of a lot, in water (e.g. channel dredging In Moreton
               Bay) etc.)
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     2. — \dentify if any of the following apply to the premises by completing Tables D, E, or F. (Note: In most instances, the premises will not Involve any of
          the following characteristics, however some applications may involve one or more of these characteristics - complete onty if applicabte)