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Appendix L Self Declaration Form

This document is a self-declaration form and affidavit by Midhun Varghese affirming that all measurements in the civil plan are correct and that fire protection arrangements are compliant with the National Building Code of India. It includes details about the building's occupancy, location, and compliance with fire safety standards. The owner acknowledges potential fines for ineffective fire protection arrangements during inspections.

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Midhun Varghese
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482 views2 pages

Appendix L Self Declaration Form

This document is a self-declaration form and affidavit by Midhun Varghese affirming that all measurements in the civil plan are correct and that fire protection arrangements are compliant with the National Building Code of India. It includes details about the building's occupancy, location, and compliance with fire safety standards. The owner acknowledges potential fines for ineffective fire protection arrangements during inspections.

Uploaded by

Midhun Varghese
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

169

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. Midhun Varghese Name:


[Link].:
Address:
(Registered Institution/ Architect/Engineer/
Town Planner/ Supervisor)

AFFIDAVIT

Name and address of the applicant : Midhun Varghese, Pulimoottil House, Vadavathoor PO,Kottayam

Occupancy of the building : Residential

Survey Number : 294/2

Village : Manarkadu, Kottayam

Panchayat/Municipality : Manarkadu, Kottayam

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

This is a digitally signed Gazette.


Authenticity may be verified through [Link]
170

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
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: Manarcadu Signature of Applicant

Date: 29/03/2025 Name: Midhun Varghese

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]

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