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APPENDIX - L
[See rule 5(4)]
SELF DECLARATION FORM
I do hereby declare that all the measurements mentioned in the civil plan are correct, and complete.
I also hereby declare that all the required fire protection arrangements as listed in the National building
code are installed in the building and are ready for inspection and testing.
(Signature) (Signature )
Name of Owner. Name:
Reg. No.:
Address:
(Registered Institution/ Architect/Engineer/
Town Planner/ Supervisor)
AFFIDAVIT
Name and address of the applicant :
Occupancy of the building :
Survey Number :
Village :
Panchayat/Municipality :
I/We do hereby affirm that,
1. the materials proposed to be used or installed for the construction of the building will be as per
required fire resistant rating in NBC of India – 2005, Part IV Annexure C
2. all the proposed installations and power supply fixed for the proposed building will be as per
NBC of India 2005 Part IV Annexure C
3. all the proposed Air conditioning, Smoke Management, Ventilation and staircase Pressurization
systems for the building, if installed, will be as per NBC of India Part IV Annexure C
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4. all the proposed lightning protection installations for the building will be as per NBC of India
2005 Part IV Annexure C
5. the proposed gas bank for the building, supply lines and other fitting associated with it, if
installed will be as per NBC of India 2005 Part IV Annexure C
Place: Signature of Applicant
Date: Name:
Note:— If on any subsequent inspection the fire protection arrangements are found to be ineffective, the
owner of the building shall be liable to pay fine @ Rs.100 per sq. meter build up area, not exceeding
Rs.1,00,000/- in total.
This is a digitally signed Gazette.
Authenticity may be verified through [Link]