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FORM -1
(Prescribed under Rule 3)
APPLICATION FOR PERMISSION TO CONSTRUCT, EXTENT OR
TAKE INTO USE ANY BUILDING AS A FACTORY
(To be submitted in triplicate)
Application for
(Tick one or more as applicable)
a) Constructing of a new building
b) Extending an existing building
c) Taking into use any building as a
factory
Applicants name and residential address
(In block letters)

Full name and postal address of the factory

(a) Name of Factory
(b) Address of Factory

Town or village:

District:
Please indicate also following details

Pin Code:

(a) Nearest Police Station & distance

(b) Nearest Railway Station
(c) Nearest Public Hospital
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(a) Whether already registered as factory

(b) If yes,
(1) Registration No.

Yes/No

(2) Licence No.

(3) Date of renewal of licence

(c) Does it fall in hazardous category under

Section 2(cb)
(d) If so, has site been approved U/s 41A?
(e) Is so, date of approval
Particulars of plant to be installed:

Yes/No
Yes/No

* To be enclosed only if the site has not

been appraised in terms of Section 41A.
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Enclosures
(a) Flow chart of the manufacturing process
(b) Brief description of the process in its
various stages.
(c) Plan, in triplicate, drawn to scale
Showing
i. The site of the factory and immediate
surroundings, including adjacent
buildings and other structures, roads,
drains etc.
ii. The plan, elevation and necessary crosssections of the various buildings
indicating all relevant details relating to
natural lighting, ventilation and means
of escape in case of fire.
The plans shall also clearly indicate the
position of the plant and machinery, aisles and
passageways.
(d) Such other particulars as required by the
Chief Inspector at the time of submission
of the application.

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Signature of applicant:
Name of applicant(In block letters):
Telephone number:

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