FORM –11.

( See rule 31)

Form for application for permission to erect structure or building in a Gram.

(To be submitted in duplicate)

PART –I

To

The Pradhan,

_____________ Gram Panchayat.

Sir,

I hereby apply for permission to erect a structure/building as mentioned in Column 1 of the table below in the place covered by Plot No. ___________.  Survey No. ___________ situated in ______________ village within the jurisdiction of Tahsil ___________, the boundaries of which are given below, on payment of the fee indicated in column 2 of the said table.

THE TABLE

**

(a)   Thatched/Tin/Tile shed without brick-wall covering an area measuring

       between 20 sq.meters and 40 sq.meters                                                                          Rs.2.00

(b)    Thatched/Tin/Tile shed without brick-wall covering an area above 40  sq meters                 Rs.4.00

(c)    (c)  Brick-walled one storied structure for housing per five sq.meters or part thereof           Rs.3.00

(d)  Brick-walled one storied building or structure for commercial purpose per five

       Sq.meters or part thereof                                                                                                Rs.5.00

(e)(i) Brick-walled structure or building or more than one storey for housing purpose

         per five sq.meters or part thereof                                                                                   Rs.5.00

    (ii) Brick walled structure or building of more than one storey for commercial

          purpose per five sq. meters or part thereof                                                                     Rs.7.00

  (iii) Shop/Shed where upto 10 persons are employed per five sq. meters or part

          thereof                                                                                                                          Rs.10.00

  (iv) Shop/Shed where more than 10 persons are proposed to be employed per five

        sq. meters or part thereof                                                                                                  Rs.12.00

  (v) Other permanent structure to be used for commercial or business purpose per five

        sq. meters or part thereof                                                                                                   Rs.15.00

Boundaries   

East by Plot No. ________ S.No._________

West by Plot No.________ S.No._________

East by Plot No. ________ S.No._________

West by Plot No.________ S.No._________

2.         I hereby undertake to raise the walls of the proposed structure/building after leaving the set back under rule 36-C (for  residential purpose)/under rule 36J for commercial prupose. ££

3.                   I hereby declare that I have undisputed right, title and interest in the land on which the structure/building is proposed to be constructed.

4.         A also hereby declare I am not erecting any structure or building either near or in the vicinity of

any areodrome tending to hazard aviation or near any prohibited area.

## Score out whichever is not applicable.

** Score out items not applicable.

                                                                                                    Signature:

                                                                                                   Address : 

   Date :

PART - II

ORDER OF GRAM PANCHAYAT

1.       Permission is hereby accorded to Shri/Smti.---------------------------------------------- to erect a structure/building in the place covered by Plot No.-----------------S.No.-------------as per his/her application dated-------------------(vide meeting dated-------------------------).

2.      Permission is hereby refused to erect a structure/building in the place covered by Plot No.------------------S.No.-----------------------(vide meeting dated----------------------) for the reason stated below :

Reasons :

1.

2.

3.

4.

5.

Dated--------------------------                                                        Signature

                                                                                                      Pradhan

                                                                                                     Seal.

(Strike off words which are not applicable.)

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To

The Pradhan,

Gram Panchayat__________

            Kindly refund the fee or Rs.__________ paid vide Receipt No. ________ dated_______ on account of permission to erect a structure/building vide application dated _______ which has since been refused.

Signature :

Address :

Date :

PAY ORDER.

Pay Rs.__________ (Rupees____________________) to Shri/Smt________________.

Signature of Pradhan

Seal

Date :

Note :  As soon as the permission is granted or refused, the application may be informed of the position and the fee refunded if permission is refused after obtaining the signature of the applicant.