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C(>NG HOA xA H(>I CHU NGHiA VItT NAM

Dqc ljp - Tv do - Htmh phuc

BIEN BAN THAM DJNH HI."E:N T~G BAT D()NG SAN (Ap dl!ng a6i vai tai san la blit dong san ngo(Ji lrir chung cu)

I. Thong tin chung: Chuyen vien th\fC hien khao sat: NGO DUY LUAN Chuyen vien th\TC hien bao cao: NGO DUY LUAN Dan vi .......... .. ... - .... · .......... ... ........ .. ...... .... ...... ......... ... . Dan vi: ... ....... .. . .... .. .. ..... . Thcri gian khao sat: . . .. ...... .. .. . Thcri gian tiep Thcri gian chuyen thong tin: . Thcri gian hoan t N gum yeu cau tharn djnh ..... .. .. ' Dia chi BOS tharn djnh: ........ ..... ... .

TI. K~t qua thim djnh hifn t~ng:

l. - H~=c~hv~~ ~&:!:!~ nh~ QSDD s6: .. ....... ....... .... ........ J!fJ_;_q6.ltt: ...................................... . - Crui c~ vao HQll d6ng s6: ........ .... .. .......... 7/,,/{.0-:..c!l/. .. .J....J[J{ .. ::-:. ... ,.9:r.JJtJ!. ................................. ..

2. l>ic diem hi~ . . . . i' Dia chi tren GCN*: .... . .......... .. .

Dia chi th\fc t€* : Nhtr GCN GCN: ... ... ........................... .......... ...... ................ ............... ........... ..... .. .. ..

H(l.tfuigxahQi: Hi!- tfuig ky thu~t:

Ten tr\lC duong chinh: ............... Ten dtrong ti€p giap: ..

Do rong ngo/ngach nh6 nh&t (rn): ...... ...... . .. .. ..... ............. DQ r{,ng rn~t duong ti .L .... .. Lo(l.i duong ti€p giap: Nh\fa tong

Vi tri theo quy dinh NN: Khoang each d€n ( chg/TTTM/truong hQc/ benh vienlb€n xe ):

········· ··· ··· ···· ···· ····· ·· ···· ······ ·· ··· ·· ··· ········· ······················ Rtii ro lien quan (n€u c6): ... ... .. ...... . .. ....... ... . .. ... .. . .. ....... ..... ...... ... ....... .... ......... .. ... .. ..... ... ......... . ... ........... .

De cr Kinh doanh, lam van phong M\lc dich sir d\!Ilg hien 1(1.i Nha xuong D Khac: .. .. .. .. .... ...... .... .. .

Thong tin quy ho(l.ch Khong quy ho(l.ch

uy ho(l.ch khac: .. .. ... hu{,c quy ho(l.ch

Mot phan thu{,c quy ho(l.ch

c6t n~n Th&phan Caohan Gan song/kenh/ao ho.

Gful duong ray, ho~c nha ga.

Cac y€u t6 v~ xii h{li, rnoi truong G§n bai rac trong ban kinh I 00 Ill.

G§n rn{,, nghia trang, nha tang I~ ban kinh I OOrn.

Gful chua, nha tho, dinh, am trong ban kinh 100m.

Gan Chg, sieu thi, trung tam.

C6 ducmg dam vao nha

Cac y€u 16 v~ lc;ri th€ kinh doanh Khu dan CII sfun uk

iu kinh do~ buon ban nh6 le Khu phu hgp de iJ

Cac y€u t6 khae: .................. .... ..................................................

Hifn tn,rng thfra dit ¥eo Giiy chU11g nhin Theo th\J'C ti -

T6ng di~n tich thua d~t (m2): ........ . 0.fJ./!J.·-:_················ 9-i6ngGCN KhaeGCN:

Di~n tieh su d\lilg rieng (m2): .... ... .Jfi./2. .................... i9ibngGCN

Di~n tieh su d\mg ehung (m2): ...... .... 0 .............................. ~\li6ngGCN KhacGCN:

Kich thu6e chi~u n)ng (m): ........... ..1U./3J .. -:;. .. ·········· ···· i9ibngGCN

Kich thu6c ehi~u dai (m)/ ....... ...... .JU/"J!J. ................... <fongGCN KhacGCN:

Hinh di!Dg thua d~t: tf' Hinh chil nh~t. Hinh vuong. dGibngGCN ' D KhacGCN: Hinh da giac. Hinh ehil L. D Hinh niJ h~u

Hinh t6pMu Hinh g~p khuc Hinh dang khac

Hu6ng ehinh: KhaeGCN:

Bae Nam Tay Bae Nam

Hu6ngph\l:

Hu6ngph\l:

Hu6ngph\l:

~.~.~.~~t/lJ..L~ s6 I: M\le dich su d\lilg s6 2: M\le dfch su d\lDg s6 3: M\le dich sir d\lilg s6 4:

····························· ··············'"············· ........................... ..

Di~n ticJ.ltrrieng Di~n tich su d\lng rieng Di~n tieh su d\lng rieng Di~n tich sir d\lng rieng (m2): .... .. (m2): ...... .. .. ..... (m2): ............... (m2): .... .... .......

~!~:~'.~~l!..~.\IIlg ehung Di~n tich sir d\lng chung Di~n tich su d\lilg ehung Di~n tich sir d\Jllg chung (m2): ....... .... (m2): .............. (m2): ... .... ....

Thoi hi!D sir d\Jllg: JD Thoi hi!D sir d\lllg: ...... Thoi hi!D sir d\Jllg: .... .. Thoi hi!D su d\Jllg: ......

Ngu6n g6c: ............... Ngu6n g6e: ....... ......... , ' Nguon goe: ....... ........ Ngu6n g6e: .... .... ........

Sa do vj tri BDS tham djnh (ve hinh dang su b9, vi tri va airimg ai vao BDS)

IS"&

Glri chu: Cong trinh xay d\ffig tren dat: !:'.!Co

2

3. Cong trinh xay dlfllg tren dit:

Lolli c6ng trinh*: QNha a d(>c l~p li~n k~ Nha Bi~t th\! scrM.n phong ..... .. ............ ... .... .

Phap ly CTXD*: EfKhong C6: ...... .. ..... .. ......... ... ...... .. .. ............ ...... .. .. ............. ....... ...... ... ............................. ... ....... ... .

Ten c6ng trinh* : .............. Nn.a.. ... 6-............................... ......... . /

Tinh tlq.ng cong trinh*: CTXD chua hoan thanh

0 CTXD m6i CTXD dll qua sli d\lflg

Ccr SCJ tinh toan* : scr phap ly r1' Do d(IC th\IC t€ Di~n tfch d§t xay d\Illg (m2) *: ......... W. ....................... . T6ng s6 tfulg cao*: .......................... 0............. ....................... Tfulg h~m•: ...... ...................... @ ......... ............................... . T6ng di~n tich san Xay dµng (m2) tinh toan*: .. .... ---;/lf) .... .... Nru:n xay dµng* : .................... QS){l ... ........ ..... ............ . T6ng di~n tich san Xay dµng (m2) theo phap ly* : ...... .................... ... .;. ........ .. ............. .... .. .. ................ ................................ .

K€t ciu chinh: / - Mong: tf¥1°CT .......... Hi~n tlq.ng: ... ....... ...... \ .......... .... .. .. ... ... ......... ............ ... .... .. ..... .. ... ..... .

- Khung c(>t: dsTCT Oyfu!p ........... Hi~n t1q.ng: ................... ..................... ............................................... .

- Tuong: :Eii~ch .......... Hi~n t1q.ng: ....... .... .... ') ... To.J. .. .......................... .............................. . - N~n,san: . ch ........... Hi~n tlq.ng: ....................... 9.!:. .......................................................... . - KC do mai: ep ........... Hi~n tlq.ng: .. .. .......... .. ....................................................... ................ .

- Mai: ~g6i ............. Hi~n lri!Dg: ....... ...................... .. ..................................... .. .......... .. .. .

Rui ro lien quan (n€u c6): ............................................. ····· ··· ·· ·· ·····/ ················· ··················· .. ············· ······················· ·· ····--·········

Lo~i c6ng trinh *: Cong trinh xay dµng khac ................... ;. ........... ... ........... .. .......................... ... .. ........... ........ .. .............. .

Phap ly CTXD*: C6: .......... ................... ....... / ............................................... ................. ...... .......... .. .. ............. ..

Ten cong trinh*: .. ........................................... .. ........ ... .. .... / .... K€t c§u*: .................... .. ............ .. .. ................... .. .............. .

Ccr SCJ tinh toan* : scr phap ly Do d(IC th\IC ? Nru:n xay d\Illg*: ..... .. .............................................................. ..

T ' d.. , hlkh '· 1 • d tinh ~-• ./ H .• tran . d * ong •~n tic 01 ugng xay \fllg toau : ...... .... .. ... ..... •~n . g su \lflg : ................ ... ........................................... .

T6ng di~n tich/ kh6i lugng xay d\Illg theo phap Iy/ .............. .. ... ............ .. .................................. .................... .. ....... ............... .. .

Rui ro lien quan (n€u c6): ................. ... ........... .. ~/ .... ..... .. ............. .. ....... ... ......... ........ ... ................................... ...... ... ............ .. ... .

.• b' d h' . /' .. . / '1/t()_/ AfllY/ Bien an 11.et t uc vao uc ..... .. ..... ...... ...... .. . g1a .............. , ngay ... . f!l./. .. .. ....... U<.L<x.-f

Cac hen ilii i19c /qi va il6ng y Icy ten. CHU TA.I SA.N/NGUOI HUONG DAN NGUOI TIIVC D~I DIE:N KIEM soAT VIEN THAM DJNH VIEN - T6i cam k€t tai san duqc hmmg d~ tren RI¥N KHAo SAT NGAN HANG (Ky va ghi ro h9 ten) (Ky va ghi ro h9 ten) day chinh la tai san ghi trong gi§y chlillg (Ky va ghi ro h() ten) (Ky va ghi ro h9

dung S\I th~t, n€u sai toi se chiu trach / nh~ va thong tin cung c§p la hoan toan ten)

nhi~m truoc phap lu~t. 1/ ~~3'.1.~~ .. .. .. NGO DUY LUAN j~

(Ky va ghi ro h9 ten)

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