417 APPENDIX: Al [See rules 5(1)(t), 75(1), 87(1) and 93(1)] APPLICATION FOR PERMIT/REGULARISATION Municipal Corporation / Municipal Couneil / Town Panchayat ‘Applicant(s) | Owner(s) 1, Name in capital letters Addvess @ Pemanent adévess of the owner (i) Towhich communications are tobe sent 3. Nature of developm ent/construction: @ Division of plot Gi New construction (i) Reconstruction (Alteration /Additin/Extension Digging of well (9) Change in occupancy (i) Demolition (ii)Roof changing 4. Details ofplot @ Revenue Villge ( (@SuveyNo © RenuveyNo (i) Sub Division ) Tatu (9) Distsict (o) Extent in Sqn This ie digtally sigue Gee -Anchenticay maybe verted trough eps: campos kara gov118 (ai) Natwe of ownership (ait) Number and date of deed/ Document Ge) Regutia's Office @ Wado (ed) Avthotised number of the nesret building (ei) NemestBlechic Pos/Telecom Post munber 5. Whether the lend, if any, contiguous to this plot of the owner shown in the site plan Rule 6(4)(@)@): Yes (No 6. Usage of surrounding plots in general North East South West 7 Whether Government or Quasi Government 8. Details of the Construction @ Details of Proposed Bullding(s) Building ne. Building no.2 Occupancy. Occupancy Height of the building m__ | Height of the balding = Use | Bultup ‘Area Use | Builtup ] Area provided Floors sea | provided for wea | forperking Gam) | parking Gam) | inside the inside the ‘building ‘building Gam) Gqm) Basement loot Ground floor Total ad sapavate sheat Frequaved dily signed by both the licenses and the Owner This ie digtally sigue Gee -Anchenticay maybe verted trough eps: campos kara gov Eh119 (@ Details of Existing Building.) Building ne. 1 Building no.2 Occupancy. Occupancy. Height of the building m__ | Height of the balding = Use | Bultup “Area Use | Builtup ] Area provided Floors sea | provided for wea | forperking Gam) | parking Gam) | inside the inside the ‘building ‘building Gam) Gqm) Basement loot Ground floor Total ald separate sheat Freqived diy signed by both the licenses and the Owner Gi Total Built-up Area Gs) Total Covered Area (o) Total parking area provided inside the building’) () Total Built-up Area for FSI 9. Basic KMBR Verification w xt. proposed plot SL] Rule [Descaption Requsedipemisnble | _ Provided No. | No 1 [Access width to the plot 2 Coverage 3 Floor Space Index 10, Besic KMBR Verification wrt proposed building(®) (@ Building no. 1 SLNo. [Rue No. Desciption Requsedpamisatle | Provided 1 [Access width to the building Gam) Minimum distance from the ebutting road/access to other building(s) (in metre) No. of Four wheeler parking This ie digtally sigue Gee -Anchenticay maybe verted trough eps: campos kara gov120 Woof Two-wheder parlin No. of Parking for Differently abled No. of Parking for Vistors Loadingfunloading space (#9, metre) Set Backs Gnmet) Front Side [ Side? Rear Exit Wid Gameve) No. of Stair case(3) No. of Fise Escape Stair case(9 Rainwater storage capacity Gn litre) ‘Add separate sheet if required duly signed by both the licensee andthe — Owner 11, Provisions of Town Planning Schemes, if eny, applicable to the construction © Zoning 3] Wane Fe TP Tag Zane | Penney of propo Ne Scheme (Smnctoned! construction as per the heme Published) (Rosa Widening Saba su | Nameoe | stage | Erising | Propord | pune | Be | sotoack No, | gheTP | Ganetiontd | oad Gn | soad Gin [UM C |Bristing road | Oded scheme | “Pasa 204 | sord Ga Ty SY YBrisingron | Foy am) 12, Permissibility with respect to Kerela Conservation of Paddy Lend and Wet and Act 2008 / KLU order 1967 This ie digtally sigue Gee -Anchenticay maybe verted trough eps: campos kara gov@ Type of land as per BTR @ Type of land as per Date Bank 13, If the epplicetionis for regularisation @ Whether construction completed or not i) Tfnot completed, the stage of construction 14, Details of permit/approved plan already obtsined 15, Details of fee paid ‘Application fee Layout scrutiny fee @ Amount (i) No. end date of receipt 16, Details of documents, plans certificate, ete. enclosed, 17, Details of NOC obtained. SL. [Required [Whether enclosed or not [Details of the NOC /Clearences 18, DECLARATION 1, hereby declare thet the measurements, specifications and other details mentioned above are correct, complete and true to the best of my knowledge and belief and that I shall abide by the epproved plan and the provisions in the Act and Rules in undertaking the construction Place: Signature of the applicent with name Date: This ie digtally sigue Gee -Anchenticay maybe verted trough eps: campos kara gov122 19 CERTIFICATE Certified thet the site plan is prepered after verification of ownership document and site and the measurements shown are found to be correct. Signature: Nome: Place RegNo. Date: Addcess (Registered Institution, Architect, Engineer, Town Planner, Supesviso:) 20. CERTIFICATE Cestified thet the building plan is prepered in accordance with the provisions in the Kerala Municipality Building Rules 2019, Kerala Municipality Act, 1994 and the provisions contained in the sanctioned Town Planning Schemes, if eny. Place Signature Date: Name RegNo. Addeess (Registered Institution/Architect/ Engineet! Town Planner/Supervison) a UNDERTAKING 1, hereby undertake that the building construction and/or land development will be cassied on/ being certied on/ was carried on as per the approved plan and permit in accordance with the rules in force Place Signature Date Name RegNo Adavess (Registered Institution! Architect/Engineet! Town Plannes/ Supervisos) This ie digtally signed Gear ‘Achsticty may be verted droughts eempose era gov