CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
N XIN CP GIY PHP SA CHA, CI TO
(S dng cho Cng trnh, nh ring l th)
Knh gi:.........................................................................................
1. Tn ch u t:..................................................................................................
-CMND s..................................cp ngy..........................................................
-a ch thng tr:............................................................................................
-S nh:............................ng:.......................................................................
-Phng (x)......................................Qun (huyn):.........................................
-Tnh, thnh ph:................................................................................................
-S in thoi:....................................................................................................
2. a im xy dng:...........................................................................................
L t s:........................Din tch......................................................m2
Ti s nh:......................ng:.......................................................................
Phng (x)....................Qun (huyn).............................................................
Tnh, thnh ph:................................................................................................
Ngun gc t:..................................................................................................
Chng ch quy hoch s (nu c) s:................................................................
3. Ni dung xin php xy dng:...........................................................................
- Loi cng trnh:.................................................................................................
- Din tch xy dng tng trt.....................................m2.....................................
- Tng din tch sn....................................................m2.....................................
- Chiu cao.....................................................tng...............................................
4. n v hoc ngi thit k:...............................................................................
- a ch:..............................................................................in thoi:..............
- Giy php hnh ngh (i vi nh c chiu cao trn 3 tng v din tch sn
trn 200m2).
5. T chc, c nhn thm nh thit k:..............................................................
- a ch:...........................in thoi:.................................................................
- Giy php hnh ngh s: .....................cp ngy................................................
6. Li cam kt: Ti xin cam oan lm theo ng giy php c cp; nu sai
ti xin hon ton chu trch nhim v chu x l theo quy nh ca php lut.
................., ngy........thng........nm..........
XC NHN CA UBND PHNG (X, TH TRN)

NGI LM N
(K, ghi r h v tn)