KONSULTAN PENYEDIA JASA
LOGO DAN IDENTITAS PEMILIK KERJA
No Form. No. : Nomer :
NAMA PROYEK
Format Lampiran : Tanggal : ….. /…../…...
SURVEY LAHAN
Kepada Yth. :
Konsultan Pengawas/MK
Up. Team Leader
Bersama ini disampaikan permohonan persetujuan Ijin Peralatan pekerjaan, sebagai berikut :
1 Jenis Pekerjaan : S A MEP LANSKAP LAINNYA …............
2 Area Survey :
NO URAIAN KETERANGAN
1 Fungsi Bangunan : ................................................................................................................... ...............................................................
2 Luas Lahan : ................................................................................................................... ...............................................................
3 Batas Tanah : ................................................................................................................... ...............................................................
Timur : ................................................................................................................... ...............................................................
Barat : ................................................................................................................... ...............................................................
Utara : ................................................................................................................... ...............................................................
Selatan : ................................................................................................................... ...............................................................
4 Kontur Tanah : ................................................................................................................... ...............................................................
5 Jenis Tanah : ................................................................................................................... ...............................................................
6 Lingkungan : ................................................................................................................... ...............................................................
7 Jalan Akses : ................................................................................................................... ...............................................................
8 Sumber Air : ................................................................................................................... ...............................................................
9 Listrik : ................................................................................................................... ...............................................................
10 Telepon : ................................................................................................................... ...............................................................
11 Gas Negara : ................................................................................................................... ...............................................................
12 Lalu Lintas : ................................................................................................................... ...............................................................
13 Bangunan Sekitar : ................................................................................................................... ...............................................................
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CATATAN KONSULTAN MK
Diajukan Oleh : Diperiksa Oleh : Disetujui Oleh:
Penyedia Jasa Konsultan Pengawas/MK Konsultan Pengawas/MK
Manajer Proyek Tenaga Ahli Team Leader