The Vice-Chairman,
Urban Development Authority,
Visakhapatnam-530 003 (A.P.)

I hereby give notice that I intend to carry out development in the site to erect / to re-erect demolish / renewal / extension / addition / change of use in the building ___________________________________________on / in plot No.____________ Land, Town and Survey No.____________________ Block No.___________________ situated at road / street______________ town / village _________________.

I forward herewith the following plans and statement (item 1 to 10) whatever is applicable, in quadruplicate signed by me (Name in block letters) _____________________________ and the Licensed______________ License No.__________________ who has prepared the plans, designs along with copies of the statements / documents.

1. Top plan to a radius of 100 m.
2. Site plan.
3. Sub-division / Layout plan.
4. Building plan.
5. Service plan.
6. Parking arrangements.
7. Particulars of development.

a. Horse Power.
b. Product Mix.
c. Nature of Industry - Small scale - Gramodaya Scheme.
d. Other operation details whether it is pollutant heavy industry.

8. N.O.C. from Air & Water Pollution Board, if it is a pollutant and hazardous industry.
9. Ownership title.
10. Urban Land Ceiling Clearance certificate from Competent Authority.
11. Draft drawn in favour of Vice Chairman, VUDA towards Development Charges / Building License fee for Rs.__________________.

I request that the proposed development / construction / extension may be approved and permission accorded to me to execute the work.

Signature of Licensed                                                                                                                                                                 Signature of Owners
Surveyor / Engineer / Architect with stamp. 
                  

Signature of Licensed                                                                                                                                                                 Name of Owner.                                                                                                                                                                                                                      Address of Owner.