Skmbt_C280-12111513221

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fs Is owner's consent required for this application? (refer to notes at the end of this form f for more information) |

 

>] No

L] Yes - complete either table D, table E or table F as applicable

Fy

i Does the application involve a state resource? (og. the ®pplication involves state land, or taking quarry |

 

[etetials Refer to the notes at the end of this form for more information)

x] No (Yes - complete table G

 

 

[10. identify if any of the follawing apply to the premises (tick applicable box/es) Tine ,
L] adjacent to a water body, watercourse or aquifer (e.g creek, river, lake, canal) - complete table H
(] _ on strategic port land under the Transport Infrastructure Act 1994 - complete table |

C1 __ ina tidal water area - complete table J

 

[t* Are there any existing easements on the premises? (@.g. for vehicular access. electricity, overland flow,
water, etc.)

=

[No Yes - ensure the type, location and dimension of each easement is included in the plans submitted

 

(12. Does the proposal include new building work or operational workon the Premises? (including any
| services)

(JNo Yes - ensure the nature, location and dimensions of Proposed works are included in plans submitted

 

143. Is the payment of a portable long service leave levy applicable to this application? {refer to the notes at the
| end of this form for more information)

L] No - Go to question 15 XI] Yes

 

information)

 

Ime Has the portable long service leave levy bean pald? (refer to noies at the ond of this form for riore

 

X] No

complete table K and submit with this application the yellow local government/ private certifier's copy of
C1 Yes - .
the receipted QLeave Form

 

15. Has the local government agreed to apply a superseded planning scheme to this application under
_Section 96 of the Sustainable Planning Act 20097

—& No
LL) Yes - provide details below

 

A als = DAS fom 7
Version 1.0 18 December 2009