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1. Pemeriksaan Interim MPKj / OSC / BGN / INT - 2014 MAJLIS PERBANDARAN KAJANG MENARA MPKJ, JALAN CEMPAKA PUTIH OFF JALAN SEMENYIH, 43000 KAJANG 03-8737 7899 Samb 3037, 3152 FAX : 03-8736 4639 BORANG SEMAKAN URUSETIA OSC PEMERIKSAAN INTERIM MAKLUMAT PEMOHON 1. Nama dan Alamat : ________________________________________________ (PEMILIK) ________________________________________________ ________________________________________________ ________________________________________________ No. Kad Pengenalan : ________________________________________________ No. Telefon/H.Phone : ___________________ No. Faks : _________________ 2. Nama dan Alamat : ________________________________________________ (PSP) ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ No. Telefon/ H.Phone : ___________________ No. Faks : _________________ 3. Tajuk Permohonan : ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ 4. No. Fail OSC : MPKj OSC/_______________________________________ 5. No. Fail J. K. Bangunan : ________________________________________________ 6. Tarikh Kelulusan Pelan : ________________________________________________ Bangunan Tandatangan dan Cop Perunding Tarikh *Borang ini perlu ditaip MPKj / OSC / B25 - 2015 SENARAI SEMAK PEMERIKSAAN INTERIM Bil. Semakan Semakan Bil Dokumen Yang Diperlukan Dokumen Pemohon OSC 1. Surat Permohonan Pemeriksaan Interim kepada 1 OSC 2. Surat Permohonan Pemeriksaan Interim kepada 1 teknikal terlibat (SYABAS, TNB, JKR, JBPM, DOSH, IWK, JPP , KEJ dan JKB 3. Borang Kesediaan Pemeriksaan Interim 2 (SYABAS, TNB, JKR, JBPM, DOSH, IWK, JPP , KEJ dan JKB MPKj / OSC / B25 - 2015 BORANG PEMERIKSAAN INTERIM SYARIKAT BEKALAN AIR SELANGOR (SYABAS) Pengurus Kanan, Syarikat Bekalan Air Selangor, Suite C-2-30, Tower C, Wisma Goshen, Plaza Pantai, No. 5, Jalan 4/83A, Off Jalan Pantai Baru, 59200 KUALA LUMPUR. Tuan / Puan Saya mengesahkan *skop kerja Syarikat Bekalan Air Selangor (SYABAS) bagi projek ....................... Tajuk Permohonan ............................................................................................................................................. di atas lot No Lot Nama Mukim ............................... mukim .................................... telah memenuhi kehendak agensi peringkat interim dan bersedia untuk pemeriksaan interim oleh agensi. ............................................................... ( Orang Utama Yang Mengemukakan ) Nama Perunding : .................................... No. Pendaftaran : ..................................... Tairkh: ...................................................... MPKj / OSC / B25 - 2015 BORANG PEMERIKSAAN INTERIM TENAGA NASIONAL BERHAD Pengurus Besar Negeri (Selangor), Bahagian Pembahagian TNB, Aras 6, Wisma TNB Subang Jaya, Jalan USJ 10/1A, USJ 10, 47620 SUBANG JAYA Tuan / Puan Saya mengesahkan *skop kerja Tenaga Nasional Berhad (TNB) bagi projek ..................................... Tajuk Permohonan ............................................................................................................................................. di atas lot No Lot Nama Mukim ............................... mukim .................................... telah memenuhi kehendak agensi peringkat interim dan bersedia untuk pemeriksaan interim oleh agensi. ............................................................... ( Orang Utama Yang Mengemukakan ) Nama Perunding : .................................... No. Pendaftaran : ..................................... Tairkh: ...................................................... MPKj / OSC / B25 - 2015 BORANG PEMERIKSAAN INTERIM JABATAN KESELAMATAN DAN KESIHATAN PEKERJA (DOSH) Jabatan Keselamatan dan Kesihatan Pekerja (DOSH) Tingkat 7, Wisma Consplant 2, Jalan SS16/1, 47500 SUBANG JAYA. Tuan / Puan Saya mengesahkan *skop kerja Jabatan Keselamatan dan Kesihatan Pekerja (DOSH) bagi projek Tajuk Permohonan ....................................................................................................................................... di atas lot No Lot Nama Mukim ............................... mukim .................................... telah memenuhi kehendak agensi peringkat interim dan bersedia untuk pemeriksaan interim oleh agensi. ............................................................... ( Orang Utama Yang Mengemukakan ) Nama Perunding : .................................... No. Pendaftaran : ..................................... Tairkh: ...................................................... MPKj / OSC / B25 - 2015 BORANG PEMERIKSAAN INTERIM INDAH WATER KONSORTIUM (IWK) Indah Water Konsortium Sdn. Bhd. Agensi Perakuan – Pembentungan (Negeri Selangor) Lot 11-02, Level 11, Block D, Menara Pandan, Persiaran MPAJ, Jalan Pandan Utama, Pandan Indah, 55100 KUALA LUMPUR. Tuan / Puan Saya mengesahkan *skop kerja Indah Water Konsortium (IWK) bagi projek ..................................... Tajuk Permohonan ............................................................................................................................................. di atas lot No Lot Nama Mukim ............................... mukim .................................... telah memenuhi kehendak agensi peringkat interim dan bersedia untuk pemeriksaan interim oleh agensi. ............................................................... ( Orang Utama Yang Mengemukakan ) Nama Perunding : .................................... No. Pendaftaran : ..................................... Tairkh: ...................................................... MPKj / OSC / B25 - 2015 BORANG PEMERIKSAAN INTERIM JABATAN KEJURUTERAAN MPKj Jabatan Kejuruteraan Tingkat 5, Menara MPKj, Jalan Cempaka Putih Off Jalan Semenyih, 43000 Kajang Selangor Darul Ehsan Tuan / Puan Saya mengesahkan *skop kerja Jabatan Kejuruteraan bagi projek ..................................... Tajuk Permohonan ............................................................................................................................................. di atas lot No Lot Nama Mukim ............................... mukim .................................... telah memenuhi kehendak agensi peringkat interim dan bersedia untuk pemeriksaan interim oleh agensi. ............................................................... ( Orang Utama Yang Mengemukakan ) Nama Perunding : .................................... No. Pendaftaran : ..................................... Tairkh: ...................................................... MPKj / OSC / B25 - 2015 BORANG PEMERIKSAAN INTERIM JABATAN KERJA RAYA (JKR) Jurutera Daerah, Pejabat Jurutera Daerah, Jabatan Kerja Raya, Hulu Langat, Persiaran Wawasan, Seksyen 14, 43650 BANDAR BARU BANGI. Tuan / Puan Saya mengesahkan *skop kerja Jabatan Kerja Raya bagi projek Tajuk Permohonan ............................................................................................................................................. di atas lot No Lot Nama Mukim ............................... mukim .................................... telah memenuhi kehendak agensi peringkat interim dan bersedia untuk pemeriksaan interim oleh agensi. ............................................................... ( Orang Utama Yang Mengemukakan ) Nama Perunding : .................................... No. Pendaftaran : ..................................... Tairkh: ...................................................... MPKj / OSC / B25 - 2015 BORANG PEMERIKSAAN INTERIM JABATAN BOMBA DAN PENYELAMAT MALAYSIA (JBPM) Ketua Zon, Jabatan Bomba Dan Penyelamat Malaysia, Pejabat Bomba Dan Penyelamat Zon Hulu Langat, Jalan Pandan Utama, 55100 PANDAN INDAH. Atau Pengarah, Jabatan Bomba Dan Penyelamat Malaysia, No.3, Persiaran Tebar Layar, Bukit Jelutong, Seksyen U8, 40150 SHAH ALAM Tuan / Puan Saya mengesahkan *skop kerja Jabatan Bomba Dan Penyelamat Malaysia bagi projek Tajuk Permohonan ............................................................................................................................................. di atas lot No Lot Nama Mukim ............................... mukim .................................... telah memenuhi kehendak agensi peringkat interim dan bersedia untuk pemeriksaan interim oleh agensi. ............................................................... ( Orang Utama Yang Mengemukakan ) Nama Perunding : .................................... No. Pendaftaran : ..................................... Tairkh: ...................................................... MPKj / OSC / B25 - 2015 BORANG PEMERIKSAAN INTERIM JABATAN PERANCANGAN PEMBANGUNAN MPKj Jabatan Perancangan Pembangunan Tingkat 3 Menara MPKj, Jalan Cempaka Putih Off Jalan Semenyih, 43000 Kajang Selangor Darul Ehsan Tuan / Puan Saya mengesahkan *skop kerja Jabatan Perancangan Pembangunan bagi projek Tajuk Permohonan ................................................................................................................................................................. No Lot Nama Mukim di atas lot ............................... mukim .................................... telah memenuhi kehendak agensi peringkat interim dan bersedia untuk pemeriksaan interim oleh agensi. ............................................................... ( Orang Utama Yang Mengemukakan ) Nama Perunding : ...................................
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