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Form Permohonan Izin Gangguan

Form Permohonan Izin Gangguan

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Dipublikasikan oleh Ochie Bella Oktasari

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Published by: Ochie Bella Oktasari on Sep 23, 2012
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11/08/2013

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FORMULIR PERMOHONAN IZIN GANGGUAN

Kepada Yth.
Kepala Badan Promosi Investasi & Pelayanan Perizinan Terpadu
Kab. Bintan
Di Tanjungpinang
Lamp.
!al
Yang Bertanda tangan di ba"ah ini
#ama ........................................................................................................
Tempat Tinggal ....................................................Telp............................................
Kelurahan .............................................. Ke$amatan.......................................
Dengan ini mengaju%an permohonan Izin &angguan untu%
a. 'saha baru d. Bali% nama dan ganti nama
b. Perluasan usaha e. Perpanjangan izin gangguan #o. .....................................
$. Pindah tempat usaha .................................... Tanggal .......................................
Keterangan Perusahaan
a. #ama Perusahaan ........................................................................................................
b. #ama Pemili% ........................................................................................................
$. (enis 'saha ........................................................................................................
........................................................................................................
d. )lamat tempat usaha ........................................................................................................
...............................................................Telp..................................
Kel.............................................Ke$amatan....................................
e. *tatus tempat usaha ........................................................................................................
+. Bentu% Badan 'saha ........................................................................................................
g. ,odal 'saha ........................................................................................................
h. Tenaga Kerja ........................................................................
i. Luas tempat usaha ........................................................................
Pernyataan-persetujuan
Keterangan Nama Persetujuan Tanda Tangan
Pemili% Tempat
Tida% Keberatan - Keberatan
Tetangga 'tara
Tida% Keberatan - Keberatan
Tetangga Timur
Tida% Keberatan - Keberatan
Tetangga *elatan
Tida% Keberatan - Keberatan
Tetangga Barat
Tida% Keberatan - Keberatan
Tanjungpinang.
!ormat %ami.
#o. ...................................... #o. ...................................... #o. ...........................................
/T. ..................................... /0. ..................................... L'/)! ...................................
#o. .............................................
1),)T .....................................

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