SURAT KETERANGAN PERSETUJUAN TETANGGA

Yang bertanda tangan dibawah ini :

1. Nama : ..................................................................................................................................................
Alamat : ..................................................................................................................................................
...................................................................................................................................................
No. KTP : ..................................................................................................................................................

2. Nama : ..................................................................................................................................................
Alamat : ..................................................................................................................................................
...................................................................................................................................................
No. KTP : ..................................................................................................................................................

3. Nama : ..................................................................................................................................................
Alamat : ..................................................................................................................................................
...................................................................................................................................................
No. KTP : ..................................................................................................................................................

Menyatakan bahwa sesungguhnya kami benar-benar tidak keberatan adanya Pendirian, Renovasi,
Perluasan Bangunan/Bangun Bangunan peruntukan :
(........................................................................................................................................................................)
Sepanjang tidak mengganggu lingkungan yang dilakukan oleh :
Nama : ..........................................................................................................................................
Alamat KTP : ..........................................................................................................................................
..........................................................................................................................................
Lokasi bangunan : ..........................................................................................................................................
..........................................................................................................................................

Demikian Surat Keterangan Persetujuan Tetangga ini dibuat dengan sebenarnya, untuk
dipergunakan sebagai salah satu persyaratan pengajuan Surat Izin Mendirikan Bangunan (SIMB).

Depok, ...................................................
Mengetahui Yang membuat pernyataan
Ketua RT Ketua RW
1.

2. Materai
Rp.6000,-

(.......................................................) (.......................................................)
3.