Form A

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Form-A

Application for Permission for subdivision/layout or reconstitution or amalgamation


of land for building purposes. And for change of use of land

From

--------------------------

-----------------------------

------------------------------ (Affix stamp


size photo-
graph of the
applicant)

To

The Competent Authority

……………………………………………………

1. I/We hereby apply for permission for subdivision / layout or reconstitution or


amalgamation of land for building purposes as described in the accompanying plans and
drawings.

2. I/We have absolute right over the land applied for and have not made any
encroachment on any government land.

3. The names of the persons employed by me/us for the preparation of plans, and
supervision of the work are as under:

a) The plans are prepared by Registered Architect/Engineer/Town


Planner ------------------- [name]

b) The execution of the development will be supervised by Registered


Architect/Engineer/Town Planner-------------[name]

4. I/We have read the Building Rules applicable for the Local body wherein the site
lies and claim to be fully conversant with it; I/We will abide to the provisions of the Building
Rules fully.

5. I/We shall fulfill my duties and responsibility in accordance with the provisions of
the Building Rules.

Date: Signature of the Owner/Developer

Signature of Registered Professional


1. Applicant’s name :

2. Postal Address for correspondence :

Telephone number for communication:

e mail ID

3. Applicant’s right over the land to make the proposed

development: (documentary evidence to be enclosed)

4. Development site address :

5. Extent of the site applied for :

6. Present use of the land and the existing :

Building if any [Please give details of each use]

7. Proposed use of land and/ the building,

[Please give details of each use] :

8. Whether the site applied for forms part of/lie in

an approved layout. If yes, please give date of

approval and reference no, with a copy of the

approved layout plan duly authenticated :

9. Existing use of the adjoining lands in

the North -

the East -

the South -

the West -

10. The width and status of the abutting road

(i.e. private or public)

11. Whether all the documentary evidences,

plans details, certificates required to be

enclosed with the application as per the

Building Rules have been enclosed:

Signature of Owner/Registered
Developer or

Authorised agent of the owner:

Date

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