‫ﺭﻗﻢ ﺍﳌﺨﻄﻂ‪...................................................................

:‬‬ ‫‪@ ÷†ÔÛa@Œ×Šß@M@´†äè½a@òibÔã‬‬

‫ﺍﻟﺘﺎﺭﻳﺦ‪................................................................................ :‬‬ ‫…‪@ òîäÐÛa@æëû’Ûa@ñŠöa‬‬
‫ﺭﻗﻢ ﺍﻟﻌﻘﺪ‪........................................................................ :‬‬ ‫‪@ ÕîÓ†nÛa@áŽÓ‬‬

‫ﺍﺳﺘﻤﺎﺭﺓ ﺗﺪﻗﻴﻖ ﺍﳌﺨﻄﻄﺎﺕ‬

‫”ﺗﻌ ‪‬ﺒﺄ ﻣﻦ ﻗﺒﻞ ﻣﻨﺪﻭﺏ ﺍﳌﻜﺘﺐ“‬

‫ﺍﺳﻢ ﺍﳌﻜﺘﺐ ﺍﳌﺘﻌﺎﻗﺪ‪ .............................................................. :‬ﺭﻗﻤﻪ‪ ............................. :‬ﺗﺼﻨﻴﻔﻪ‪............................. :‬‬

‫ﺍﺳﻢ ﺍﳌﺎﻟﻚ‪.............................................................................................................................................................................. :‬‬
‫ﺭﻗﻢ ﺍﻟﻘﻄﻌﺔ‪ ............................... :‬ﺭﻗﻢ ﺍﳊﻮﺽ ﻭﺍﲰﻪ‪ ...................................... :‬ﻣﻦ ﺃﺭﺍﺿﻲ‪.................................... :‬‬
‫ﻧﻮﻉ ﺍﻟﺘﻨﻈﻴﻢ‪ ......................................... :‬ﻋﺪﺩ ﺍﻟﺸﻘﻖ‪ .................................... :‬ﻋﺪﺩ ﺍﻟﻄﻮﺍﺑﻖ‪..................................... :‬‬
‫ﻣﺴﺎﺣﺔ ﺍﳌﺸﺮﻭﻉ‪............................................ :‬‬ ‫
ﻣﻘﺘﺮﺡ‬ ‫ﻃﺒﻴﻌﺔ ﺍﳌﺸﺮﻭﻉ‪
:‬ﻗﺎﺋﻢ‬

‫ﺍﺳﻢ ﻭﺗﻮﻗﻴﻊ ﻣﻨﺪﻭﺏ ﺍﳌﻜﺘﺐ‪................................................................ :‬‬

‫‪< <ê†Ö]<Ý]‚~j‰øÖ‬‬
‫ﺍﳌﺮﻓﻘﺎﺕ‪:‬‬
‫ ﻣﺬﻛﺮﺍﺕ ﺣﺴﺎﺑﻴﺔ‬ ‫ ﻓﺤﺺ ﺍﻟﺘﺮﺑﺔ ﺃﻭ ﺍﺗﻔﺎﻗﻴﺔ‬ ‫ ﻋﻘﺪ ﺍﳋﺪﻣﺎﺕ ﺍﳍﻨﺪﺳﻴﺔ‬
‫ ﺍﺳﺘﻤﺎﺭﺓ ﻣﺎﻟﻴﺔ ﻟﻐﺎﻳﺎﺕ ﺍﻟﻔﺮﻭﻉ‬ ‫ ﳐﻄﻂ ﻣﻮﻗﻊ ﻭﺗﺮﺳﻴﻢ ﺃﺻﻠﻲ‬ ‫ ﺍﳌﻠﺤﻖ ﻟﻌﻘﺪ ﺍﳋﺪﻣﺎﺕ‬
‫ ﳕﻮﺫﺝ ﺇﻋﻔﺎﺀ ﻛﻮﺗﺎ‬ ‫ ﳐﺎﻟﺼﺔ )ﺇﻥ ﻭﺟﺪﺕ(‬ ‫ ﺗﻜﻠﻴﻒ ﺍﻟﻌﻤﻞ‬
‫ ﻟﻮﺣﺔ ﻏﻼﻑ )‪(A4‬‬ ‫ ﺗﻘﺮﻳﺮ ﺇﻧﺸﺎﺋﻲ‬ ‫ ﺇﻗﺮﺍﺭ ﺇﺷﺮﺍﻑ‬
‫ ﳕﻮﺫﺝ ﻋﻄﺎﺀﺍﺕ ﺣﻜﻮﻣﻴﺔ‬ ‫ ﳐﻄﻂ ﺍﳌﺴﺎﺣﺔ ﺍﻷﺻﻠﻲ‬ ‫ ﻓﻴﺸﺔ ﺃﺗﻌﺎﺏ‬
‫ ﺃﺧﺮﻯ‬ ‫ ﺇﺛﺒﺎﺕ ﺃﻗﺪﻣﻴﺔ‬ ‫ ﻓﻴﺸﺔ ﳐﺘﱪ‬

‫ﻣﻼﺣﻈﺎﺕ‪:‬‬
‫ﺗﻮﻗﻴﻌﻪ‪.................................................................. :‬‬ ‫ﺍﺳﻢ ﻣﺪﻗﻖ ﺍﳌﻌﻠﻮﻣﺎﺕ‪............................................................. :‬‬

‫ﻣﻼﺣﻈﺎﺕ ﺭﺋﻴﺲ ﻗﺴﻢ ﺍﻟﺘﺪﻗﻴﻖ‪....................................................................................................................................... :‬‬

‫‪......................................................................................................................................................................................................‬‬
‫ﺗﻮﻗﻴﻊ ﺭﺋﻴﺲ ﻗﺴﻢ ﺍﻟﺘﺪﻗﻴﻖ‪.................................................................. :‬‬

‫ﺗﻮﻗﻴﻊ ﻣﻨﺪﻭﺏ ﺍﳌﻜﺘﺐ )ﺑﺎﻃﻼﻋﻪ ﻋﻠﻰ ﺍﳌﻼﺣﻈﺎﺕ(‪.................................................................. :‬‬