ANNEXURES TO GOMs.NO. 168 MA & UD, DATED: 07.04.2012

358APPENDIX – XIVFILE No.Name of the Urban Local BodyTOWN PLANNING SECTIONBUILDING APPLICATION SELF-SCRUTINY STATEMENTSl.NoSl.NoSl.NoSl.NoCSCTPWardNo.CircleNo.ZoneNo.YYYY.Sub: Building Application for grant of permission for Construction of………………………………………………………................................................………………………………………………………………………………………………Notice u/s 209 & 227 of APM Act, 1965 / 428 & 433 of HMC Act, 1955.Date of submission at CSC dd mm yyyyPART: IBASIC INFORMATIONAADDRESS OF THE APPLICANT1 Name2 Door No./Flat No.3 Road/Street4 Locality / Mandal5 City PIN6 District7 Phone / Mobile No.8 e-mailB LOCATION OF THE PROPOSED SITE10 Plot No.11 Sanctioned Layout No. / LRS No.12 Survey No. Village13 Premises / Door No.14 Road/ Street15 Ward No. Block No.16 Locality17 Circle Division18 City/ Town DistrictC DETAILS OF BUILDER / LICENSED PERSONNELS.No.Name Address License No. Validity1…………………………………Builder / Developer2……………………………………Architect/Engineer/Surveyor