001A666E.001

__ “iE GRATED PLANNING ACT 1997                                                                                          Part A, Version 3.1, 3 March 2008
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      PUR Sig Reagent                                                                                             ee
      10.   The Portable Long Service Leave Levy (PLSL) is not applicable to this application if any of the following apply: { Tick box if applicable)
             [_] the application seeks a preliminary approval only;
             (J the application is not for building and construction work under the Building and Construction Industry (Portable Long Service
                 Leave) Act 1991, section 3AA (e.g. the application is onty for a change of use, or for the following types of work carried out solely for
                 farming purposes: land clearing, site preparation, earthworks, fences, fodder harvesting, clearing of encroaching vegetation, clearing of
                 regrowth, thinning vegetation or controlling weeds or pests);
             [_] all costs, that relate to the work both directly and indirectly, are less than $80,000, inclusive of GST; or
          - [[) the work is being carried out under an owner-builder permit issued under the Queensland Building Services Authority Act 1991 -
@                Complete and submit a QLeave Notification and Payment Form (no payment required if owner-buitder permit number stated). The receipted form must be
                 sighted by the assessment manager before a development permit can be given.

      11.    Is payment of a PLSL levy applicable to this application? (Refer to Q10 and the Advice below for more information)?
               [[]   No -EndofParta                                       |
               oy    Yes - Answer Q12 below                  :                             .
      OFFICE USE ONLY (For use by the Assessment       beer’ Private Certifier) (Optional)
       Fee ($)                Date received                        Receiving officer's  p                           Reference |    .
                LSS                             Le [ul                   name           PS      Rea                  numbers | ©        /sot

         .                                       .                Council. | have been engaged as the private certifier for the building work referred to in this
e To:            o     _    NI OAS                                                                                                         application.

      1304                  “Peter                Lusio                                             AQ ILS |
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                       QLEAVE NOTIFICATION AND PAYMENT (for completion by assessment manager or private certifier if applicable)
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                       (Brick) Dwelling
      Privacy Statement
      The information collected on Form 1 will be used by the Department of Infrastructure and Planning (DIP) in accordance with the processing and assessment of your Application.
      Your personal details will not be disclosed for a purpose outside of the IDAS process, except where required by legislation (including the Freedom of Information Act 1992) or as
      required by Parliament. This information may be stored in a DIP database. The information collected will be retained as required by the Public Records Act 2002.
      Advice for completing Part A