001A666E.001

__* INTEGRATED PLANNING ACT 1997                                                                                         Part A, Version 3.1, 3 March 2008
      Table D   Complete if the premises are adjacent to or associated with a water body, watercourse or aquifer (e.9. river, creek, fake, canal)

      Table E   Complete if the premises are on Strategic Port Land under the Transport Infrastructure Act 1994
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     Table F    Complete if the premises are in tidal water

     3.    Indicate the total area of the premises on which the development is proposed: (Note: The total area may include tand both above and below water)

            810.18               m           r         ick   applicable unit
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     4,    Current use/s of the premises: (e.g. vacant tand, house, townhouses, apartment building, shop, service station, school, sugar cane farming etc.)

     5.    Are there any existing easements on the premises? (e.9. for vehicular access, electricity, overland flow, water etc.)?
          [7{'No     C) Yes - Ensure the type, location and dimensions of each easement are included in plans, submitted with the application
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     6.    Brief description of the proposal (e.g. 6 unit apartment building, 30 lot residential subdivision, a bore, aquacutture)
         2     Storey             dwalling.
     7.    Does the poposal include new buildings or operational work (including any services) on the premises?
          Cl No        ar Yes - Ensure the nature, location and dimensions of the proposed works are included in plans, submitted with the application
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@ 8.      Does the application involve taking or interfering with a State resource and therefore require a resource entitiement? (e.9. the application
          involves State land (leased and freehold), declared Fish Habitat areas, taking quarry material, taking or interfering with water under the Water Act 2000, etc.)
           Ano -Go to Q9          CL] Yes - Complete Table G - provide details for each evidence required on a separate row, if applicable. Evidence of resource
                                              allocation or entitlement must be submitted with the application. You do not need fo answer Q9 - go to the next section.
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     9.   Complete Table H for applications involving a material change of use; reconfiguration of a lot; work on land below high-water mark and
          not within a canal as defined under the Coastal Protection and Management Act 1995; or work on rail corridor land defined under the
          Transport Infrastructure Act 1994 - provide details for each owner on a separate row, of on an attachment to this form if applicable.
     Table H                          ae           oO                                we                                                      a
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     * Owner's signature cannot be provided on the form if you intend to submit the application electronically. Owner's consent must be provided to the assessment manager on an
      attachment containing appropriate written documentation of the owner's consent. If the owner is a company, s127 of the Corporations Act 2001 (Cwealth) details how a
      company may sign as owner. Templates for the provision of owners consent are available on the IPA website .