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DIISI OLEH SELURUH WAJIB RETRIBUSI (WR) DAERAH

I. Keterangan Mengenai Usaha :

1. Nama Badan Usaha : ....................................................................................................2. Alamat / Lokasi Badan Usaha :

a. Jalan : ....................................................................................................b. No , ! / " : ....................................................................................................#. $esa / Kel%rahan : ....................................................................................................d. Ke#amatan : ....................................................................................................e. Kab%&aten : K%tai Kartanegara'. Nomor !ele&on : ....................................................................................................

(. )%rat I*in +ang $imiliki -o& )%rat I*in dilam&irkan :a. )%rat I*in ........................................................ No. ............................

!gl. ..................................

b. )%rat I*in ........................................................ No. ............................!gl. ..................................

#. )%rat I*in ........................................................ No. ............................

!gl. ..................................d. )%rat I*in ........................................................ No. ............................

!gl. ..................................0. olongan etrib%si :

a. etrib%si Jasa Um%m :b. etrib%si Jasa Usaha :#. etrib%si eri*inan !ertent% :

II. Keterangan emilik / engelola :1. Nama emilik / engelola : ....................................................................................................2. eker3aan / Jabatan : ....................................................................................................(. Alamat !em&at !inggal :

a. Jalan : ....................................................................................................

b. No , ! / " : ....................................................................................................#. $esa / Kel%rahan : ....................................................................................................d. Ke#amatan : ....................................................................................................

e. Kab%&aten : ....................................................................................................'. Nomor !ele&on : ....................................................................................................

0. !anda B%kti $iri : K!4. No. 5 !gl. !anda B%kti $iri :

-o& dilam&irkan

 

)UA! 6MB6I!A7UAN )!

UN!UK "AJIB 6!IBU)I " $A6A7

N.P.W.R.D

 

PEMERINTAH KABUPATEN KUTAI KARTANEGARA

BADAN PELAYANAN PERIZINANTERPADU

Komplek Perkantoran Bupati Gedung Kemar B !antaiDa"ar

Kepada #t$.Kepala Badan Pela%anan Peri&inan

 TerpaduKa. Kutai KartanegaraDi ' 

PERHATIAN :1. 7ara& diisi dalam rangka& 2 d%a , dit%lis / diketik dengan h%r%' -6!AK 82. )etelah diisi dan ditandatangani , hara& diserahkan kembali ke&ada Badan elaanan eri*inan !er&ad%

B2! Kab. K%kar &aling lambat !anggal ..................................................... 8(. Beri tanda 9 &ada kotak ang tersedia %nt%k 3aaban ang diberikan 80. $iisi dengan keadaan &ada !anggal ..................................................... 84. 7ara& mengg%nakan lembaran kertas lain , 3ika 3aaban tidak #%k%& tersedia dalam kolom )! ini .

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III. $iisi oleh "a3ib etrib%si Jasa Um%m :1. etrib%si ...............................................................................2. etrib%si ...............................................................................(. etrib%si ...............................................................................0. etrib%si ...............................................................................4. etrib%si ...............................................................................;. etrib%si ................................................................................ etrib%si ...............................................................................1?. etrib%si ...............................................................................

I9. $iisi oleh "a3ib etrib%si Jasa Usaha :1. etrib%si ...............................................................................2. etrib%si ...............................................................................(. etrib%si ...............................................................................0. etrib%si ...............................................................................4. etrib%si ...............................................................................;. etrib%si ................................................................................ etrib%si ...............................................................................1?. etrib%si ...............................................................................

9. $iisi oeh "a3ib etrib%si eri*inan !ertent% :1. etrib%si I*in er%nt%kan engg%naan !anah

a. Nilai !anah : ....................................................................................................b. L%as !anah 4.??? M / Lebih : ....................................................................................................#. er%nt%kan : ....................................................................................................

2. etrib%si I*in Mendirikan Bang%nan IMBa. L%as Bang%nan M2 : ....................................................................................................b. Jenis Bang%nan : ....................................................................................................

#. Nilai / 7arga Bang%nan : ....................................................................................................d. er%nt%kan : ....................................................................................................(. etrib%si I*in !em&at en3%alan Min%man Beralkohol

a. L%as !em&at Usaha : ....................................................................................................

b. olongan Min%man Keras : ....................................................................................................#. @m*et en3%alan / 7ari : ....................................................................................................

0. etrib%si I*in angg%ana. L%as !em&at / Kegiatan : ....................................................................................................

Usaha M2 / 7a b. Indeks angg%an I : ....................................................................................................#. Indeks Lokasi IL : ....................................................................................................d. Jenis er%sahaan :

  er%sahaan ang mengg%nakan mesin dengan intensitas gangg%an besar / tinggi 8er%sahaan ang mengg%nakan mesin dengan intensitas gangg%an sedang 8er%sahaan ang mengg%nakan mesin dengan intensitas gangg%an ke#il 8er%sahaan ang tidak mengg%nakan mesin dengan intensitas gangg%an besar/tinggi 8er%sahaan ang tidak mengg%nakan mesin dengan intensitas gangg%an sedang 8er%sahaan ang bebas gangg%an

4. etrib%si I*in !raeka. J%mlah Armada : ....................................................................................................b. No. olisi : ....................................................................................................#. J%r%san !raek : ....................................................................................................

;. etrib%si I*in engambilan / em%ng%tan 7asil 7%tan Ik%tana. Jenis 7asil 7%tan : ....................................................................................................b. 9ol%me Kg / !on : ....................................................................................................#. 7arga asaran &. : ....................................................................................................

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+ang bertandatangan di baah ini :

  N a m a :

Menatakan baha )%rat emberitah%an )! ini Kami / )aa isi dengan benar ,lengka& dan bersarat .

"a3ib etrib%si ,

  . . . . . . . . . . . . . . . . . . . . . . . . . ..

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$II)I @L67 6!UA) 6N6IMA B2! KAB. KUKA

$iterima !anggal :Nama et%gas :NI. :