For Office Use

Reference No.
Application Date D D M M Y Y Y Y

Application for Non Agricultural Permission

Applicant Details

Aadhaar Number

Full Name *

Gender * Male [ ] Female [ ] Transgender [ ]

Date of Birth * DD MM YYYY

Residence Address *
(Please provide the following
details)
 House/Flat No.
 Building No. /Building
Name
 Society/Complex Village Taluka
 Road Name
District Pin Code

Mobile No.

Land Line ( std code )

Email

Service Specific Details

Agricultural Industrial Commercial Residential

Type of assessment of land *
[ ] [ ] [ ] [ ]

Details of the type of grant applied for (Select type of grant applied for and briefly state gist of any condition ) *

Assessed or held for the purpose of agriculture for

[ ]
non agricultural purpose/purposes of

Assessed or held for the purpose of non-agriculture

[ ] for non-agricultural purpose but in relaxation of
condition

Assessed or held for the purpose of non-agriculture

for non-agricultural purpose but in relaxation of
[ ]
condition imposed at the time of grant of land for
permission for such non- agricultural use viz.

Is applicant Alienated land Occupant Class I Occupant Class II Tenant Govt. Lessee
superior holder of
land by* [ ] [ ] [ ] [ ] [ ]

Details of the Land for which NA Certificate is Required*

Village Taluka

District Gat Number

Area (Sq. Mt.) Assessment/rent

Details of area of site out of above proposed to be used for (in Sq. Mt.) *

1 Residential

2 Industrial

3 Commercial

Any other non-agricultural

4
purpose

Municipal Corporation /
Yes [ ] No [ ]
Council Jurisdiction
Is the city survey done? Yes [ ] No [ ]
Does it fall under
jurisdiction of cantonment Yes [ ] No [ ]
or bordering one?
Does it fall under notified
regional plan under
Yes [ ] No [ ]
Regional and Town
Planning Act 1966
Is there any of the following within 30 meters

Is the land in any of the a. Railway Stations/Railway Line Yes [ ] No [ ]

following? *
b. Airport Yes [ ] No [ ]

c. Jail Yes [ ] No [ ]

d. Public Office Yes [ ] No [ ]

e. Cemetery Yes [ ] No [ ]

If yes, distance from proposed land

Is there any high tension electricity line
above the land or within the distance of 15 Yes [ ] No [ ]
meters?
If yes , what is the distance of proposed
building from such a HT line
Is the land under
Yes [ ] No [ ]
acquisition? *
State the present use of
land and whether any
building exist thereon
and if so, its use*
If there is no approach
road, how the provision
being made to access the
location? *
Was any prior application
submitted for NA
Yes [ ] No [ ]
permission for the same
land? *
If yes, why was it
rejected?
Self Declaration

I ____________________________ son/daughter of ________________________________aged

______ occupation ________________________ resident of ______________________________
hereby declare that the information provided above is true and correct to the best of my knowledge, information
and belief. I fully understand the consequence of giving false information. If the information as given above is
found to be false, I shall be liable to prosecution and punishment under section 199 and 200 of IPC 1960 and/or
any other law applicable thereto.

Place : _________________ Applicant Signature : ______________________________

Date : ___ / ___ / ________ Applicant Name : ______________________________

List of documents to be attached

(mark [ √ ] in case necessary annexure are attached else mark [ X ])
Mandatory Documents

1 Site report including 7/12 Extract and mutation entries [ ]

2 Certified copy of record of rights [ ]

3 Drawing of the proposed building and site layout showing roads/ other transportation means [ ]

4 No objection Certificate (NOC) from PWD [ ]

5 No Objection Certificate (NOC) from owner of other land if approach road goes through that land [ ]

6 Written consent of tenant/superior holder/occupant [ ]

Additional Documents to be produced as applicable

1 Urban Ceiling Act 1976 is applicable, then No objection Certificate under the same Act [ ]

(Fields marked with * are mandatory)