APPENDIX- A1

(See rules 5(1)(b), 75(1), 87(1) and 93(1))

APPLICATION FOR PERMIT/REGULARISATION

…………………………………………………………. Panchayat

1. Name in capital letters :

Applicant(s) Owner(s)

2. Address:

(i) Permanent address of the owner :

(ii) To which communications are to be sent :

3. Nature of development/construction:

(i) Division of plot :

(ii) New construction

(iii) Reconstruction

(iv) Alteration /Addition/Extension

(v) Digging of well

(vi) Change in occupancy

(vii) Demolition

(viii) Roof changing

4. Details of plot

(i) Revenue Village :

(ii) (a) Survey No

(b) Resurvey No

(iii) Sub Division

(iv) Taluk :

(v) District :
 (vi) Extent in Sq.m :

(vii)Nature of ownership :

(viii) Number and date of deed/ Document :

(ix) Registrar's Office :

(x) Ward No. :

(xi) Authorised number of the nearest building :

(xii) Nearest Electric Post/Telecom Post number :

5. Whether the land, if any, contiguous to this plot

of the owner shown in the site plan (Rule 6(4)(a)(i)) : Yes /No

6. Usage of surrounding plots in general

North :

East :

South :

West :

7 .Whether Government or Quasi Government :

8. Details of the Construction

(i) Details of Proposed Building(s)

Building no. 1 Building no. 2
Occupancy: Occupancy :
Height of the building - Height of the building - ……………
…………… m m
Floors Use Built-up Area Use Built-up Area
area provided for area provided for
(Sq.m.) parking (Sq.m.) parking inside
inside the the building
building (Sq.m.)
(Sq.m.)
Basement
floor
Ground
floor

Total
Add separate sheet if required, duly signed by both the licensee and the Owner
 (ii) Details of Existing Building(s)

Building no. 1 Building no. 2

Occupancy: Occupancy:
Height of the building - Height of the building - ……………
…………… m m
Floors Use Built-up Area Use Built-up Area
area provided for area provided for
(Sq.m.) parking (Sq.m.) parking inside
inside the the building
building (Sq.m.)
(Sq.m.)
Basement
floor
Ground
floor

Total
Add separate sheet if required, duly signed by both the licensee and the Owner

(iii) Total Built-up Area :

(iv) Total Covered Area :

(v) Total parking area provided inside the building(s) :

(vi) Total Built-up Area for F.S.I. :

9. Basic KMBR Verification w.r.t. proposed plot

Sl. No. Rule No. Description Required/permissible Provided

1 Access width to the plot
2 Coverage
3 Floor Space Index

10. Basic KPBR Verification w.r.t. proposed building(s)

(a) Building no. 1

Sl. Rule No. Description Required/permissible Provided

No.
1 Access width to the building (in
m)
2 Minimum distance from the
abutting road/access to other
building(s) (in metre)
3 No. of Four-wheeler parking
4 No. of Two-wheeler parking
 5 No. of Parking for Differently
abled
6 No. of Parking for Visitors
7 Loading/unloading space (in sq.
metre)
8 Set Backs (in metre)
Front
Side 1
Side 2
Rear
9 Exit Width (in metre)
10 No. of Stair case(s)
11 No. of Fire Escape Stair case(s)
12 Rainwater storage capacity (in
litre)

Add separate sheet if required, duly signed by both the licensee and the Owner

11. Provisions of Town Planning Schemes, if any, applicable to the construction

(I) Zoning

Sl. Name of the TP Stage Zone Permissibility of proposed

No. Scheme (Sanctioned/ construction as per the scheme
Published)

(ii) Road Widening

Set Back
Required
Existing Proposed
Name of Stage Building from Set back
Sl. Width of Width of
the TP (Sanctioned/ Line Existing provided
No. road (in road
Scheme Published) (in m) road (in m)
m) (in m)
boundary
(in m)
12. Permissibility with respect to Kerala Conservation
of Paddy Land and Wet Land Act 2008 / KLU order 1967. :
(i) Type of land as per BTR :
(ii) Type of land as per Data Bank :

13. If the application is for regularisation,

(i) Whether construction completed or not :

(ii) If not completed, the stage of construction :

14. Details of permit/approved plan already obtained.

15. Details of fee paid: Application fee Layout scrutiny fee

(i) Amount

(ii) No. and date of receipt

16. Details of documents, plans, certificate, etc. enclosed.

17. Details of NOC obtained.

SL . Required Whether enclosed or not Details of the NOC /

no Clearances

18. DECLARATION

I,…………………………………………………………….………………hereby declare that 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 approved plan and the provisions
in the Act and Rules in undertaking the construction.

Place: Signature of the applicant with name

Date:
19. CERTIFICATE

Certified that the site plan is prepared after verification of ownership document and site and the
measurements shown are found to be correct.
Signature:
Name:
Place: Reg.No.:
Date: Address:
(Registered Institution, Architect, Engineer,
Town Planner, Supervisor)

20. CERTIFICATE

Certified that the building plan is prepared in accordance with the provisions in the Kerala
Panchayat Building Rules 2019, Kerala Panchayat Raj Act, 1994 and the provisions contained in
the sanctioned Town Planning Schemes, if any.

Place: Signature:
Date: Name:
Reg.No.:
Address:
(Registered Institution/Architect/
Engineer/Town Planner/Supervisor)

21. UNDERTAKING

I,………………………………………………..hereby undertake that the building construction

and/or land development will be carried on/ being carried on/ was carried on as per the approved
plan and permit in accordance with the rules in force.

Place: Signature:
Date: Name:
Reg.No.:
Address:
(Registered Institution/
Architect/Engineer/Town Planner/ Supervisor)