POLICE STATION :

West Bengal From No. 393 Z (141

",: :: i . -,' .: ,' .:

APPLICATION FORMUnder Section 15 to the West Bengal Fire Service Act. 1950 (West Bengal ant XVilt of 1950)as subsequently amonded. read Government Notifiaction No.81 3lF2E-1.01/63 dt.23.2.65

under ection 23(1) of th€ Act.

To

The CollectorFire Licence (Licence Section)Howrah.

Sir,Under the provisions of section 15 of the West Bengal Fire Services Act, 1g50 (West Bengal

Act XVlll of 1950), as subsequentty amended. l/We beg to apply for neMrenewal Licences for my/ourwarehousp/workshopdeSclbqdb9low'fo1thepariodofopeyeqrwitheffeetformtheA plan (duplicate) of the warehouse/rriolkshop diawn'to the sbalb of one metre'to a centimeters, isannexed herewith.

Yours faithfutly,(BLOCK LETTERS)

Signature in Full :

Name in Full :

Address in Full :

Present :

Parmanent:

Date:

Number and date of last License issued, if any :

1. Ward No.

2. Premises No.

;i:, r:ii'ai : ,r:

.-*T4'- :Narne and maximum quantity of the article or each of the articles to be stored, pressed or kept

6. Name of owner of the building or place

7 . Name of occupiers with their office address

8. Annual municipal value of the werehouse/workshop or annual value as assessed by the

Collector

9. Description of structure and nature of occupancy with immediate 20 feet all round of the

proposed werehouse/workshop

10. Name of the insurance Company, lf the premises be insured

1 1 . Exact number of water / sand bucket and extinguishers provided on site and each indicated on

plans

12. Total floor area of the werehouse/workshop (each floor separately)

13.State water --

(i) Sprinkleris installed........;........ ..............:.

(ii) Hydrant system is installedi if so, give capacity of pump in gallons per minute and normalworking pressure and number of hydrants f itted ........,.,,....................,.......;........,......,....,...:.-...."..

(iii) Distance of nearest open water (i.e. river or tank) with access, details and approximate areand depth ...... ...........

..;......... ..........:'..'.'.::iir;::::.......::.............................:....tiS.rtgh+.t*,....,8t...kI*Ag.**-,