Appendix B — Form for Certificate of Supervision

Reference number: _________________________

Address of the site:

Plot number: _____________________________ Holding number: ___________________

Street name: _____________________________

Municipal ward number: ___________________

Type of intended work (Check one) :

Develop                Erect              Demolish                    Alter

Name of the owner:     ______________________________________________________
Contact address:       ______________________________________________________

______________________________________________________
______________________________________________________

Post code:             ____________________
Telephone no:          ____________________

I hereby certify that the building for which the location, the type of work, and the name and address of owner appear above will be supervised by me as per the provisions of the Bangladesh National Building Code.

______________________________________________
Signature of the engineer, architect, planner or supervisor

__________________________________________
Name of the engineer, architect, planner or supervisor

_______
Address

___________                                                                   ________________
Qualification                                                                       Date