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:
Yang Bertanda tangan di bawah ini :
Nama
: ........................................................................................................
Tempat Tinggal
: ....................................................Telp............................................
Kelurahan
: .............................................. Kecamatan.......................................
Dengan ini mengajukan permohonan Izin Gangguan untuk :
a. Usaha baru
d. Balik nama dan ganti nama
b. Perluasan usaha
e. Perpanjangan izin gangguan No. .....................................
c. Pindah tempat usaha
.................................... Tanggal .......................................
Keterangan Perusahaan :
a. Nama Perusahaan
: ........................................................................................................
b. Nama Pemilik
: ........................................................................................................
c. Jenis Usaha
: ........................................................................................................
........................................................................................................
d. Alamat tempat usaha
: ........................................................................................................
...............................................................Telp..................................
Kel.............................................Kecamatan....................................
e. Status tempat usaha : ........................................................................................................
f. Bentuk Badan Usaha
: ........................................................................................................
g. Modal Usaha
: ........................................................................................................
h. Tenaga Kerja
: ........................................................................
i. Luas tempat usaha
: ........................................................................
Pernyataan/persetujuan
Keterangan
Nama
Persetujuan
Tanda Tangan
Pemilik Tempat
Tidak Keberatan / Keberatan
Tetangga Utara
Tetangga Timur
Tetangga Selatan
Tetangga Barat
No. ......................................
RT. .....................................
No. ......................................
RW. .....................................
No. .............................................
CAMAT .....................................
No. ...........................................
LURAH ...................................