RAC.BK.PPI.A03

BORANG PERMOHONAN PENYEWAAN STRUKTUR PAPAN IKLAN LUAR DI ATAS TANAH KERETAPI

i. JENIS STRUKTUR PAPAN IKLAN : SAIZ PAPAN IKLAN :ii.

C. TUJUAN SEWAAN :

B. MAKLUMAT TANAH

NO LOT / PLOT /

KILOMETER / NO. TIANG

NO. KOORDINAT

MUKIM/ PEKAN /

BANDAR DAERAH NEGERI LUAS DIPOHON

ANGGARAN JARAK DARI LANDASAN

SYARAT-SYARAT KELAYAKAN PERMOHONAN

i. Setiap permohonan akan dikenakan wang proses berjumlah RM500.00 atas nama Perbadanan Aset Keretapi (Wang proses tidak akan dikembalikan. Pembayaran hendaklah menggunakan Wang Pos, Bank draf, Kiriman Wang dan Cek.

ii. Satu (1) Borang Permohonan Penyewaan untuk satu (1) lokasi penyewaan sahaja iii. Hanya permohonan yang lengkap sahaja akan diproses iv. Jenis papan iklan dibenarkan tertakluk kepada kelulusan pelan Kebenaran Merancang oleh

Pihak Berkuasa Tempatan. v. Segala permohonan dan lampiran perlu dihantar bersama ke alamat berikut :

A. A. MAKLUMAT PEMOHON

i. NAMA ( INDIVIDU/ SYARIKAT/ PERTUBUHAN) :

ii. NO.KAD PENGENALAN (LAMPIRKAN SALINAN ) :

iii. NO DAFTAR SYARIKAT/ PERTUBUHAN (LAMPIRKAN SALINAN ) :

iv. ALAMAT :

v. NO. TEL : vi. NO. FAKS :

vii. EMAIL :

D. MAKLUMAT PAPAN IKLAN :

iii Show the railway track (distance clearance of signal pole/equipment, electrical pole, cable optic and etc)

iv Show the other utilities (utility mapping)

v Heavy machineries should be placed outside railway reserved

vi To propose heavy duty safety fencing/anti climb billboard area

To be Endorse by Certified

Surveyor/Engineer

E. PERAKUAN PEMOHON

Bahawasanya saya mengaku maklumat yang diberikan di atas adalah benar dan saya bertanggungjawab

sepenuhnya atas maklumat yang diberikan. Saya juga bersetuju dan memberi kebenaran kepada pihak

RAC untuk menyemak latar belakang pemohon melalui Sistem Data CTOS atau sebagainya.

Tandatangan : ............................................................... Nama : ............................................................... No Telefon : ............................................................... Jawatan Dan Cop Syarikat : ................................................................ Tarikh : ................................................................

KEGUNAAN PEJABAT / BAHAGIAN

TARIKH TERIMA

PENERIMA

STATUS Lengkap / Tak Lengkap

CATATAN

Billboard Application Subbmission

1 Project title (Front page)/Covering letter - Railway No. KM Marking2 Table of Contents 3 General Information4 Photo of proposed site5 Work schedule (Bar charts) in reserved railway boundary only

6 Location/Site Plan – scale 1:500i Show the railway reserved railway boundary ii Show the Railway No. KM Markingiii Show the railway track (distance clearance of signal pole/equipment,

electrical pole, cable optic and etc)iv Show the other utilities (utility mapping)

v Heavy machineries should be placed outside railway reserved

vi To propose heavy duty safety fencing/anti climb billboard area

7 Cross Sectional Plani Show the railway reserved boundaryii Show the railway track (distance clearance of signal pole/equipment,

electrical pole, cable optic and etc)iii Horizontal clearance 12.5 meter from edge of billboard structure

to nearest railway trackiv Show other utilities (utility mapping)v Propose power supply route for structure billboardvi Propose Design Footing Structure/Foundation

vii Propose pile cap minimum 1.5 metre depth from existing ground level

To be Endorse by Certified

Surveyor/Engineer

CHECKLIST APPLICATION ADVERTISING BILLBOARD

To be Endorse by Certified

Surveyor/Engineer

10 Certi�cateI Personal Track Safety Certificate (KTMB 038)ii Person Incharge of Work Certificate (PICOW) (KTMB 039)iii Lookout Certificate (KTMB 040)iv CIDB / Green Card Certificate

v Tools and machine certificatevi Crane Test Certificatevii Hoisting Machine Permit (PMA) Permitviii Workers Competency Certificate for special machine/equipmentix Competent Safety Officer/Manager/Supervisor Certificate

11 Safety Management Systemi Safety Management Charts including contact noii Emergency Response Plan (ERP)iii Fire Response Plan (FRP)iii Job Risk Assessment (JRA)/RADCiv Job Safety Analysis (JSA)v ER Team with contact numbervi Tool Box Briefingvii Records of Certificate

12 Monitoring (Track, OCS, Signalling and etc)i Monitoring Teamii Monitoring Methodiii Reports And Analysis

8 Method of Statementi Railway track and train protection methodii Install/Uninstall temporary safety fencingiii Low Displacement Pile (Bore Pile, Micro Pile and others)iv Installing of billboard structurev Install/Uninstall temporary scaffolding

vii Any types of Structure launchingviii Diagram of power supply

9 Reportsi Geotechnics Instrument (Track Settlement and Electrification Pole

Monitoring)ii Prediction of settlementiii Soil Investigation Report with summaryiv Structure design calculation with (Sub structure, structure and others)

To be Endorse by Certified

Engineer

To be Endorse by Certified

Engineer

Pengurus Besar Perbadanan Aset Keretapi (Railway Assets Corporation) Level 16, IOI City Tower 2, Lebuh IRC, IOI Resort City, 62502 Putrajaya Sepang, Selangor No Tel : 603-8939 0200 No Faks : 603-8939 0222

Segala permohonan dan lampiran perlu dihantar bersama ke alamat berikut :