COMMON APPLICATION FORM FOR

SINGLE WINDOW INDUSTRIAL CLEARANCES

To be submitted to the Office of the District Industries Centre, for obtaining clearances listed below
1. Local body clearance 2. Environmental clearance from Pondicherry Pollution Control Committee
in case of Green category 3. Conversion of land use 4. Permission for drawal of water 5. Power
feasibility 6. Permission under Factories Act 7. Clearance from Deputy Collector Revenue (Land
Acquisition) 8. Site Clearance from Town and Country Planning Department 9. Approval of
Pondicherry Planning Authority
(Please read the following instructions before filling up the form)

INSTRUCTIONS TO FILL UP THE COMMON APPLICATION FORM FOR

SINGLE WINDOW INDUSTRIAL CLEARANCES
1. All the columns in the common application form should be filled in. No columns should be left
blank. In case any of the columns not being applicable to the applicant he should state so.
2. Required number of photo copies of the filled in Common Application Form can be taken but
signature should be affixed on each copy in ink.
3. The required fee if any should be paid to relevant Department at the time of processing the
application by concerned Dept.
4. The applicant has to submit the following for obtaining the clearances.
Sl Particulars/ Documents Number of copies to be
No submitted for location
Within Outside
Indl Estate Indl Estate
1 Application form 5 8
2 Provisional Certificate of SSI / NOC for MSI & LSI
5 8
issued by Directorate of Industries & Commerce.
3 Attested copies of Land document (Sale/Lease/Rental) 5 8
4 Site and Building plan with machinery details (blue
8 12
print) drawn by the competent person
5 Project report with pollution details, process details
5 6
and flow chart
6 Partnership deed / Memorandum of Articles of
3 3
Associations / By Laws in the case of Co-op society
7 Resolution passed by the Board of directors
3 3
authorizing the applicant to sign in the application
8 Building Plan approval Form-IA for New / Additional
construction if any (or) approved copy issued by 3 4
Pondicherry Planning Authority for existing building
9 Electricity demand bill copy in the case of existing
2 2
power supply
10 Court Fee Stamp of Rs 2/- 2 2
11 Form 1C and Chalan 1+1 1+1
12 FMB Sketch in the case of Vacant Land - 4

5. If you wish to elaborate on the information called for through any of the columns in the
application you may attach separate sheets to do so.
 COMMON APPLICATION FORM FOR
SINGLE WINDOW INDUSTRIAL CLEARANCES
1. Name of the Industrial
undertaking/Factory/ Work shop

2. Name of the promoter

3. Nature of organization Proprietary Partnership Pvt./ Public Ltd Co-op. Society

3A. Nature of the application o Setting up of New Unit o Enhancement of Power

o Shifting of the existing unit o Modification of the existing unit
4. Address for communication

5. Authorised Person (The authorised person should be well versed with the project details) to be
contacted
i) Name
ii) Designation
iii) Address

iv) Phone number Office Residence Mobile Fax E-mail

6. i) Status of the Site Indl. Indl. Agricultural Commercial Public Residential Others
Estate Zone Utility

ii) Reasons for choosing the land

other than in the identified
industrial zone (If applicable)
7. Details of the site where the unit is proposed to be set up
i) Re survey Number / Block /
Town Survey Number
ii) Revenue Village Name
iii) Plot Number / Door Number
with Street Name
iv) Name of the area/Village/
Town/ Commune

8. Whether the land is owned by

the applicant or taken on lease

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9. Is the Industrial Undertaking proposed to be started in an existing building Yes No
If the answer to the above question is “Yes” please furnish the following details:
i) Whether the building is owned or leased
ii) Whether the approval of Pondicherry
Planing authority has been obtained for
Industrial use.
iii) Whether the proposal is in an Existing
old building / Newly constructed
building
Note: - Proof in case of old building and PPA approval in case new building to be furnished (if already
obtained)
10. Total area of land in possession Square Meters*
11. Total area of land required for industrial use (Breakup details such as)
(a) Main factory building Square Meters
(b) Raw materials including finished goods
Square Meters
storage yard, drying yard, etc.
(c) Administrative Building Square Meters
(d) Generator/ Boiler shed Square Meters
(e) Greenery/Garden, etc. Square Meters
(f) Any other (please specify) Square Meters
Total Square Meters
* 10,000 Sq. Mtrs = I hectare 4,000 Sq. Mtrs = 1 acre
12. In case of SSI: Acknowledgement (Part-I) Number
& Date issued by the Industries Department (or)
NOC in case of expansion / enhancement of power
13. Number & Date of NOC issued by Dept. of Inds.
&Com. (only in case of Medium & Large units)
14. Estimated project cost (Rs. in lakhs)
i) Land
ii) Building
iii) Plant & a) Indigenous
Machinery
b) Imported
c) Miscellaneous Assets
d) Others
iv) Working Capital
v) Others (please specify)
Total
15. Expected date of commencement of construction
16. Expected date of commencement of production

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17. Details of products Product Quantity Value (in Rs.)
proposed to be
produced per annum

18. Details of By -products Product Quantity Value (in Rs.)

proposed to be produced
per annum

19. i) Production capacity Product Quantity Value in Rs.

per shift

ii) No. of shifts proposed

and their timings
20 Employment: Number Skilled
of persons proposed to be Unskilled
employed Supervisory
Management
Contract
Indirect
Total
21. Employment: Number of persons Shift I Shift II Shift III
proposed to be employed per shift

22. Whether the factory will be having

any process vessels? If yes, number
of such vessels may be indicated.
23. Whether the factory will be engaged
in any hazardous operation? If so
please specify the nature of hazard.

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24. Details of plant & machinery to be installed
Total
Machinery Quantity Total Value in Rs.
H.P

25. Power requirement .….H.P .….K.V.A

i) Total Power Load (enclose separate list of
machineries with power load of each)
ii) Details of lighting load
iii) Power requirement in phased programme if any
iv) Connected Load if any
v) Anticipated Maximum Demand (KVA) (High
Tension Units Only)
vi) Details of Existing Connection (Power/ lighting/
Agriculture if any in the site with Policy No. Load
Sanction)
vii) Details of existing Diesel Generating (DG) Set or
proposed D.G set.
viii) Type of Physical segregation provided (e.g.
compound wall) from neighbouring units, if in the
same land

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26. Water supply
a) Proposed source of supply Public Bore well Private

b) Water requirement per day for: in Kilolitres

i) Process
ii) Wash
iii) Cooling/ boiler
iv) Domestic and Sanitary
v) Gardening
Total
c) Is water supply available in the site? If yes, specify
the type: well/bore well/public supply/pond/river etc
d) If it is proposed to utilise the bore well for water
supply, is the bore well in working condition or is
it required to be rejuvenated?
i) Whether the exiting bore well has been
constructed after obtaining permission from the
Ground water unit of the Agriculture Dept.? If so
copy of the permission letter to be enclosed.
ii) Power policy number along with the copy of the
latest current consumption bill may be enclosed
e) Is any bore well in existence in nearby areas? If so
specify the distance from the site.
f) Is it proposed to use Yes/No K. litres
i) Recycled water
ii) Treated waste water
27. Details of Raw materials proposed to be used
Requirement Indigenous /
Raw Material Value (in Rs.)
per day Imported
1.
2.
3.
4.
5.
28. Whether the manufacturing process flow chart
and process details are enclosed separately
29. Is any recycled material from the waste of
your industry or any other industry used in the
process? If so, specify quantities and source.
30. Is any material salvaged from the waste
stream reusable economically for any other
purpose? If so, specify details of quantities
and probable use.
31. Source of process know-how in house /
National laboratory / Foreign/others (specify)

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 32. Have you considered less polluting
process alternative? If yes, reasons
for adopting the present process
33. Details of emission if any
a) Source ( Process/Combustion of
fuel)
b) Type of fuel if any & quantity
c) Method of disposal/ stack height
34. Details of waste water generation if any
a) Process
b) Wash
c) Cooling
d) Domestic & Sanitary
35 Details of solid waste generation
a) Process
b) Wash/ Liquid Waste
c) Method to be adopted for the
disposal of the above
d) Air pollution control system
(APCS) proposed
36. Details of D. G. Set if any
a) No. of D. G. Set & capacity
b) Vent height
c) Noise control system if any
37. Any other remarks

I hereby declare that the above information is true to the best of my knowledge and belief.

I request that necessary clearances/ permission may be granted for the establishment of this Industrial unit

Place :
Date :
Signature of the
Proprietor/Partner/Director with seal