COMMON APPLICATION FORM FOR SINGLE WINDOW INDUSTRIAL CLEARANCES To be submitted to the Office of the District Industries Centre, for obtaining clearances listed below 1. Local body clearance 2. Environmental clearance from Pondicherry Pollution Control Committee in case of Green category 3. Conversion of land use 4. Permission for drawal of water 5. Power feasibility 6. Permission under Factories Act 7. Clearance from Deputy Collector Revenue (Land Acquisition) 8. Site Clearance from Town and Country Planning Department 9. Approval of Pondicherry Planning Authority (Please read the following instructions before filling up the form) INSTRUCTIONS TO FILL UP THE COMMON APPLICATION FORM FOR SINGLE WINDOW INDUSTRIAL CLEARANCES 1. All the columns in the common application form should be filled in. No columns should be left blank. In case any of the columns not being applicable to the applicant he should state so. 2. Required number of photo copies of the filled in Common Application Form can be taken but signature should be affixed on each copy in ink. 3. The required fee if any should be paid to relevant Department at the time of processing the application by concerned Dept. 4. The applicant has to submit the following for obtaining the clearances. 5. If you wish to elaborate on the information called for through any of the columns in the application you may attach separate sheets to do so. Sl No Particulars/ Documents Number of copies to be submitted for location Within Indl Estate Outside Indl Estate 1 Application form 5 8 2 Provisional Certificate of SSI / NOC for MSI & LSI issued by Directorate of Industries & Commerce. 5 8 3 Attested copies of Land document (Sale/Lease/Rental) 5 8 4 Site and Building plan with machinery details (blue print) drawn by the competent person 8 12 5 Project report with pollution details, process details and flow chart 5 6 6 Partnership deed / Memorandum of Articles of Associations / By Laws in the case of Co-op society 3 3 7 Resolution passed by the Board of directors authorizing the applicant to sign in the application 3 3 8 Building Plan approval Form-IA for New / Additional construction if any (or) approved copy issued by Pondicherry Planning Authority for existing building 3 4 9 Electricity demand bill copy in the case of existing power supply 2 2 10 Court Fee Stamp of Rs 2/ 2 2 11 Form 1C and Chalan 1 + 1 1 + 1 12 FMB Sketch in the case of Vacant Land - 4 COMMON APPLICATION FORM FOR SINGLE WINDOW INDUSTRIAL CLEARANCES 1. Name of the Industrial undertaking/Factory/ Work shop 2. Name of the promoter 3. Nature of organization Proprietary Partnership Pvt./ Public Ltd Co-op. Society 3A. Nature of the application o Setting up of New Unit o Shifting of the existing unit o Enhancement of Power o Modification of the existing unit 4. Address for communication 5. Authorised Person (The authorised person should be well versed with the project details) to be contacted i) Name ii) Designation iii) Address iv) Phone number Office Residence Mobile Fax E-mail 6. i) Status of the Site Indl. Estate Indl. Zone Agricultural Commercial Public Utility Residential Others ii) Reasons for choosing the land other than in the identified industrial zone (If applicable) 7. Details of the site where the unit is proposed to be set up i) Re survey Number / Block / Town Survey Number ii) Revenue Village Name iii) Plot Number / Door Number with Street Name iv) Name of the area/Village/ Town/ Commune 8. Whether the land is owned by the applicant or taken on lease * 10,000 Sq. Mtrs = I hectare 4,000 Sq. Mtrs = 1 acre 12. In case of SSI: Acknowledgement (Part-I) Number & Date issued by the Industries Department (or) NOC in case of expansion / enhancement of power 13. Number & Date of NOC issued by Dept. of Inds. &Com. (only in case of Medium & Large units) 14. Estimated project cost (Rs. in lakhs) i) Land ii) Building iii) Plant & Machinery a) Indigenous b) Imported c) Miscellaneous Assets d) Others iv) Working Capital v) Others (please specify) Total 15. Expected date of commencement of construction 16. Expected date of commencement of production 17. Details of products proposed to be produced per annum Product Quantity Value (in Rs.) 18. Details of By -products proposed to be produced per annum Product Quantity Value (in Rs.) 19. i) Production capacity per shift ii) No. of shifts proposed and their timings Product Quantity Value in Rs. 20 Employment: Number of persons proposed to be employed Skilled Unskilled Supervisory Management Contract Indirect Total 21. Employment: Number of persons proposed to be employed per shift Shift I Shift II Shift III 22. Whether the factory will be having any process vessels? If yes, number of such vessels may be indicated. 23. Whether the factory will be engaged in any hazardous operation? If so please specify the nature of hazard. 24. Details of plant & machinery to be installed Machinery Quantity Total H.P Total Value in Rs. 25. Power requirement ...H.P ...K.V.A i) Total Power Load (enclose separate list of machineries with power load of each) ii) Details of lighting load iii) Power requirement in phased programme if any iv) Connected Load if any v) Anticipated Maximum Demand (KVA) (High Tension Units Only) vi) Details of Existing Connection (Power/ lighting/ Agriculture if any in the site with Policy No. Load Sanction) vii) Details of existing Diesel Generating (DG) Set or proposed D.G set. viii) Type of Physical segregation provided (e.g. compound wall) from neighbouring units, if in the same land 26. Water supply a) Proposed source of supply Public Bore well Private b) Water requirement per day for: in Kilolitres i) Process ii) Wash iii) Cooling/ boiler iv) Domestic and Sanitary v) Gardening Total c) Is water supply available in the site? If yes, specify the type: well/bore well/public supply/pond/river etc d) If it is proposed to utilise the bore well for water supply, is the bore well in working condition or is it required to be rejuvenated? i) Whether the exiting bore well has been constructed after obtaining permission from the Ground water unit of the Agriculture Dept.? If so copy of the permission letter to be enclosed. ii) Power policy number along with the copy of the latest current consumption bill may be enclosed e) Is any bore well in existence in nearby areas? If so specify the distance from the site. f) Is it proposed to use Yes/No K. litres i) Recycled water ii) Treated waste water 27. Details of Raw materials proposed to be used Raw Material Requirement per day Value (in Rs.) Indigenous / Imported 1. 2. 3. 4. 5. 28. Whether the manufacturing process flow chart and process details are enclosed separately 29. Is any recycled material from the waste of your industry or any other industry used in the process? If so, specify quantities and source. 30. Is any material salvaged from the waste stream reusable economically for any other purpose? If so, specify details of quantities and probable use. 31. Source of process know-how in house / National laboratory / Foreign/others (specify) 32. Have you considered less polluting process alternative? If yes, reasons for adopting the present process 33. Details of emission if any a) Source ( Process/Combustion of fuel) b) Type of fuel if any & quantity c) Method of disposal/ stack height 34. Details of waste water generation if any a) Process b) Wash c) Cooling d) Domestic & Sanitary 35 Details of solid waste generation a) Process b) Wash/ Liquid Waste c) Method to be adopted for the disposal of the above d) Air pollution control system (APCS) proposed 36. Details of D. G. Set if any a) No. of D. G. Set & capacity b) Vent height c) Noise control system if any 37. Any other remarks I hereby declare that the above information is true to the best of my knowledge and belief. I request that necessary clearances/ permission may be granted for the establishment of this Industrial unit Place : Date : Signature of the Proprietor/Partner/Director with seal
