CHANGE OF LAND USE (CLU) APPLICATION AND SCRUTINY FORM

PART: II TO BE FILLED BY THE LOCAL BODY

File No.
Name of the
Date DD MM YYYY
Local Body
Ref: Date DD MM YYYY
A ADDRESS OF THE APPLICANT
1 Name
2 Door No/Flat No.
3 Road/Street
4 Village & Mandal
5 City/ Town PIN

6 District
7 Phone / Mobile No.
8 e-mail
B LOCATION OF THE PROPOSED SITE
1 Plot Nos.
Sanctioned Layout No. /
2
LRS No.
3 Survey No. Village
4 Premises / Door No.
5 Road/ Street
6 Ward No. Block No.
7 Locality
8 Circle Division
9 City/ Town District
C DETAILS OF LICENSED TECHNICAL PERSONNEL
Sl.
Name Address License No. Validity
No

………………………………
1 Architect/ Engineer/
Surveyor

D LAND OWNERSHIP INFORMATION

Sl. Document Name of the Name of the Sy. Extent Schedule of
No No. Date vendor Vendee Nos. boundaries
1 2 3 4 5 6 7 8

E DETAILS OF SITE AREA (m2)

1 As per Documents As per Submitted Plan Road Widening Area Net Area

F MASTER PLAN (GTPS) DETAILS

1 Site under reference falls in the Master Plan of ………………………………………………………Town
Status of Sanctioned G.O.Ms.No. Dt. DD MM YYYY
2 Master Plan Draft (Formally) Approved G.O.Ms.No. Dt. DD MM YYYY
Land use as per Draft / Sanctioned Master Plan
3
(Enclose Land Use Certificate, if available)
4 Extract of Master Plan enclosed YES NO
 5 Land use Proposed for Change by the applicant
Purpose for Change of Land Use requested
6
(Use & type of the proposed Building)
Whether the use and type of the building is permissible
7 as per the ZR/BR in the proposed Land use requested YES NO
by the applicant
G ACCESS (in m)
Min. Proposed road Affected in road
Directio Existing
required width as per widening
1 n road Remarks
road MP/ NH/ R&B/ Depth Area
width
width ZP/ PR (m) (Sq. m)
a North
b South
c East
d West
Site gets affected in the Proposed road widening as per MP/ NH/ R&B/ ZP/ PR
Affected land already handed over free of cost YES NO
Road
Affected land not yet handed over so far YES NO
3 widening
portion Applicant is willing to hand over the affected land free of cost,
YES NO
if CLU is considered
Affected land is acquired under LA Act/ any other provisions YES NO
H GROUND POSITION (tick (√) the appropriate one)
1 Site falls in Approved Layout
Regularized Layout / Plot
Unapproved Layout
Others (Specify)
5 Site falls in Congested Area/Abadi
Developed Area
To be Developed Area
Others (Specify)
9 Site Condition Plain Land
Undulated
Elevated from road level
Below the road level
Others (Specify)
14 Site enclosed with Fence
Compound wall
No Compound wall
Boundary Stones
Others (Specify)
19 Site Surrounded by (physical features) (Photographs shall be enclosed)
a North
b South
c East
d West
20 Whether the above YES NO
physical features Remarks:
are tallying with the
schedule of the
Documents.

RESTRICTION OF BUILDING ACTIVITY IN THE SITE & VICINITY AREA

I
(vide rule (3) of A.P. Building Rules-2012)

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 Whether the site YES NO
falls in the area If yes, give the details and specify the action to be taken:
where there are
restrictions of
building activity as
per the A.P.
Building Rules-
2012.
J ASSESSMENT REPORT FROM TRAFFIC POLICE DEPARTMENT
Whether the YES NO
assessment report If yes, give the details and specify the action to be taken:
from the concern
Traffic Police
Department is
enclosed
(in case CLU
proposed for
commercial use/
institutional use).
K DETAIL REPORT FOR ACQUISITION OF THE LAND
Whether the YES NO
detailed report for If yes, give the details and specify the action taken:
acquisition of the
land in case of the
site is earmarked
for public and semi
public use.
L FEE PARTICULARS

M DOCUMENTS TO BE ENCLOSED
1 Resolution of the Local Body No.
Date.
3 Recommendation of the Council Resolution of
the Local Body
4 Objections on the proposed activity by
neighbors if any,
5 Whether all the required documents as stated
at Part-I is enclosed, if not specify the details.
N DETAILS OF TECHNICAL SCRUTINY
Sl.
Description Remarks
No.
1 Ownership Details

2 Master Plan (GTPS)

Details & Zoning
Regulations

3 Access

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4 Ground Position &
Surrounding Details

5 Restriction of Building
Activity in the Site &
Vicinity Area
(vide rule (3) of A.P.
Building Rules-2012)

6 Assessment from
Traffic Department

7 Detail report for

Acquisition of the
Land

8 Fee Particulars

O REMARKS OF THE LOCAL BODY

1 Justification for
suggesting the
change of land use
with respect to
overall impact on the
surrounding area
(To be submitted by
the T.P. Staff)

Signature and Date

2 Remarks &
Recommendations of
the T.P. Section Head

Signature and Date

3 Final Remarks &
Recommendations of
the Commissioner/
Panchayat Secretary

Signature and Date

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