_________

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
_______________________________________

N NGH C

GI

NG NH

Knh gi: ..............................................................

nc
: ........................................................................................
- a c lin : ..............................................................................................
S nh: ................. ng
P ng (x) ......................................
n , thnh p : .............................................................................................
S in t oi: .................................................................................................
2. a im xy dng: .......................................................................................
- L t s:
Din tch ............m2.
- i: ........................................... . ................................................
P ng
(x)
Qun
( uyn)
.....................................
- n , thnh p : ..........................................................................................
3. N i dung ng cp php: ..........................................................................
- Cp cng trnh: .......................
- Din tch xy dng tng 1: .........m2.
- ng din tch sn: m2
ghi r tch sn cc
m,
trn m , k u ,
, tum).
- C iu cao cng trnh: .....m (trong
ghi r
u cao cc
m,
trn m ,
, tum).
- S tng:
ghi r s
m, trn m , k u ,
, tum)
n v o c ngi c n im t i t
(n u c ):
.............................................
- C ng c n ng s:
do Cp ngy: .....................
- a c : .................................................................................................
- in t oi:
- iy ng
doan ng ip s (n u c):
cp ngy
..................
D i n t i gian on t n c ng t n :
t ng
6. Cam t: ti xin cam oan lm theo ng giy php c cp, n u sai ti
xin hon ton c u trch n im v b x l theo quy n c a php lut
k m
u
12
......... ngy ......... thng ......... m .......
..
Ngi lm n
(K ghi r tn)