FORM E*

(See rule 11 (1))

Application for obtaining Certificate of Eligibility for exemption from payment of electricity duty under clause (vii) or clause (viii) of sub-section (2) of section 3.

Part I

1. (i) Name and address of the applicant:

(ii) Phone No.- (iii) Fax No.: (iv) Income Tax PAN No.: (v) Contact Person: (vi) Mobile No.-

(vii) E-mail Address: 2. Date of establishment of the Undertaking.

(Enclose/attach the copy of the Memorandum and Articles of Association or partnership deed.)

3. Date of commencement of manufacture or production in the State –

(i) by new industrial undertaking (section 3 (2) (vii) – i.e. first manufacturing unit in the State),

(ii) by Additional Unit of the Industrial Undertaking (Section 3 (2) (viii)).

(Enclose/attach the copies of the documents relating to the date of commencement of production and sale of goods manufactured).

4. Nature of goods manufactured or produced in the State and the details of process involved in manufacturing of such goods.

5. Whether it is an expansion of the existing business or an undertaking in the State (If yes, fill up Part I A completely).

6. Nature of business or manufacturing activities carried out previously by the applicant (details should be given).

7. The registration number obtained from Commissioner of Industries for Small Scale Industries or registration from Ministry of Commerce and Industries, Government of India (Attach copy).

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8. First and last copy of the bills for the sale of goods manufactured. (Give registration number and date under the Gujarat Value Added Tax Act, 2003 (Guj.1 of 2005) and the number and date under the Central Sales Tax Act, 1956 along with the copy of registration certificates).

9. Copy of the balance sheet of the business of applicant issued so far.

10. List of machinery with rated H.P. (Also state whether machinery purchased are new or second hand).

11. Capital investment. (Give the details of cost of each asset).

Part I A

1. Details of all locations of the undertaking in the State with connection No. / Generating Sets:

2. Whether additional unit is adjacent to any of the existing units in the State? If so, furnish following information: -

(i) Copies of documents relating to identifying the same as different, independent and identifiable premises of the existing industrial undertaking.

(ii) whether metering system of adjacent additional unit is duly tested and sealed at site by the licensee?

(iii) month wise consumption of last 36 months may be given of the existing premises.

3. Whether the capital investment in the form of building, plant and machinery is more than 100 cores in additional unit? If not, give details of investment value of all existing plants in the State as on date of commencement of manufacture or production of the additional unit.

Part II

1. Billing Officer of the licensee.

2. (I) Connected load.

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(II) Purpose for which the energy is consumed.

(III) Details of meter or sub-meter No. and the date of Installation for the following. -

(a) Motive power used for running the machinery used for manufacturing of goods.

(b) Motive power used for other purposes such as water pump, air-conditioning plant, etc.

(c) Light and fans used for the industrial purpose.

(d) Light, fans and domestic appliances used for residential, street lights, canteen, etc.

(IV) Month wise consumption of energy for different purposes as stated in (iii) above from the date of establishment.

(V) Date of connection and number given by the licensee. (Furnish the copies of the energy bills.)

(VI) The name of the person in whose name the connection stands.

(VII) Whether energy is supplied to any other person. If so, give the following details:-

(a) Rate at which power is supplied. (b) Number of separate meters

installed.

(c) Purpose for which the energy is consumed by such consumer.

(d) A copy of the agreement entered with such consumer for sale of power.

Part III

1. Date of installation of each generating set.

2. Date of starting generation of electrical energy from each generating set.

3. Copy of documents relating to the date of establishment of each generating set.

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4. Copy of documents relating to the date of starting generation from each generating set (i.e. Commissioning Report).

5. Description of place where the generating set is used.

6. Description of each generating set - (i) Make: (ii) Rated installed capacity: (iii) De-rated firm capacity: (iv) Whether thermal or diesel or back pressure turbine or by co-generation or obtained by solar, wind or biomass energy.

7. Date of purchase of each generating set (furnish the copy of each purchase bill of generating set).

8. Average daily capacity of generating set to generate energy in respect of each generating set.

9. Capacity of generating set to generate energy in terms of units per annum.

10. Registration number obtained from the office of the Collector of Electricity Duty, Gandhinagar.

11. Connected load in case of self-generation. (a) Purpose for which energy is used. (b) Meters or Sub-meters Nos. and the date of installation for the followings.-

(1) Motive power used for running machinery used for manufacture of goods.

(2) Motive power used for other purposes such as water pump, air conditioning plant, etc.

(3) Lights and fans used for industrial purpose.

(4) Lighting fans and domestic appliances used for office, residential, street lights, canteen, etc.

12. Month wise generation and consumption of self-generated energy for different purposes. (Give such information from the date of installation of generating set/s.)

13. Whether energy is supplied to other person. If so, give the following details:-

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(a) Date on which power is supplied. (b)Number of separate meters installed. (c)Purpose for which energy is consumed

by such consumers.

(d) A copy of the agreement entered with such consumers for sale of power.

14. State whether existing set is operated or not.

15. If existing set is disposed off, state the capacity of generating set so disposed off for generating the total units of energy per month and annum.

(1) Date of disposal: (2) Name and address of the party to whom generating set is sold or transferred (Furnish the copy of document relating to sale or transfer).

16. Capital investment in each generating set.

17. Details of generation and consumption of energy from other sources, if any.

Place:

Signature of Applicant Date:

Note: This application shall be made within ninety days from the date of manufacturing or production of goods for the first time; and further compliances for queries raised or information asked for, if any, be furnished within thirty days from the receipt of any correspondence, failing which application shall be deemed to be cancelled.

* revised w.e.f. 31.7.2014

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ANNEXURE – 1 (rule-3)

Application for permission to install lift or

For making additions or alterations to the installed lift

Sr

no

Particulars Details

1 Full name and permanent address of

the owner / applicant

2 Name and address of the local agent of

owner, if any (appointed under section

-14)

3 Address of the premises where the lift is

to be installed * or additions or

alterations are proposed

4 Whether a lift has been previously

erected and a license has been granted.

(Details to be given)

5 Name and address of the person

(authorized under section 13) who will

install the lift or make additions or

alterations.

6 Type and make of lift proposed to be

erected

7 Number of lifts required

8 Rated Load : Number of Persons&

Kilograms

9 Rated Speed – (Meters per second)

10 Travel in meters

11 Servings-------------------------.

Floors -------------------------.---

Entrances ------------------------

12 Method of control

13 Positions and Details of machine room

with distance of machine from the walls

of machine room.

14 Positions and details of counter weight

15 Constructions, design and finish of the

car body work.

16 Bottom car run by (in millimeters)

17 Bottom counter weight run by (in

millimeters)

18 Details of Buffer

19 Detail of call indicator.

20 Details of car frame, Platform, internal

size of car.

-

21 Details of bottom and Top counter

weight clearance.

22 Details of car and counter weight guide

rails, brackets

23 Details of car and landing doors with its

opening And locking arrangement.

24 Details of emergency stop switch, floor

leveling switch, Floor selectors and car

gate switch.

25 Details of lift pit, Lift well enclosure

and lifting beam

26 Type of lift operation with its devices.

27 Details of over speed governor.

28 Details of retiring cam / retiring ram

29 Details of safety gear

30 Details of sheave and Diverter pulley

31 Details of slack rope switch.

32 Detail of terminal slow down switch

33 Details of terminal stopping device

normal

34 Details of terminal stopping device final

35 Distance of total head room

36 Details of gear machine

37 Travel distance

38 Details of fireman switch when

required.

39 Details of main switch and wiring in

machine room,Lift well and lift pit with

position and controlling Switches.

40 Details of over current protection

41 Details of bottom and top car clearance.

42 Details of alarm system

43 Details of earthing

44 Details of emergency signal or

telephone.

45 System of roping. The number and

description, Weight and size of the

supporting cables

46 Details of lift well dimensions.

47 Details of power and lighting cable to

half way Point in lift well.

48 Details of main switch(es) and fuse(s) or

circuit breaker(s) In machine room and

main switches and fuse for isolating

Main cables to machine room(s)

49 Details of the construction of the

overhead arrangement with the weight

and sizes of the beam.

50 Proposed date for commencement of

work.

51 Proposed date for completion of work.

Signature of person referred to at

serial number -5 of above.

Authorization No:

Signature of Applicant

ANNEXURE II (See Rule 3)

Application for permission to install Escalator or for making additions or alterations to the installed

Escalator

1 Full Name and permanent Name and address

of the owner/ Applicant

2 Name and address of the local agent, if any

(appointed under section 14)

3 Address of the premised where the Escalator is

to be Erected or additions/alterations are

proposed

4 whether an Escalator has been previously

erected and License has been granted (Details

to be given)

5 Name and Address of the person (Authorized

Under section 13) who will install the

Escalator or make additions or alterations

6 Maker's name and address

7 The rated speed of the Escalator

(meter/second)

8 The rated load of the Escalator in kilograms

9 Maximum number of persons which the

Escalator can carry

10 The angle of inclination of the Escalator with

the horizontal

11 The width of the Escalator

12 The vertical rise of the Escalator

13 The number, description, weight and size of

main drive chain step chain, hand rial drive

chain & governor drive chain

14 Details of construction of the stresses and the

step threads Together with the weight and size

of all structural members And supporting

beams in connection therewith

15 Proposed date of commencement of work

16 Proposed date of completion of work

Signature of the person Customer Stamp & Sign

ANNEXURE – III

(See rule 3)

Declaration from the person authorized under section 13 for erection of lift / escalators.

We hereby declare and undertake to complete the work of erection of lift at

___________________________ for which the permission to install may be granted

under the Gujarat Lifts and Escalators Act, 2000. We also undertake the

responsibility to see that works of lift / escalators installation is inspected by the

Inspector of lift and escalators and defects pointed out by him are duly complied

with. The lift /escalators installed by us shall be handed over to the respective owner

after the licence to use the lift / escalators is issued under Section 4.

Date:

Signature of the person authorized under

Section 13 to erect lift / escalators

Authorization Number:

ANNEXURE IV

(See rule 4)

Application for a License for operating the Lifts or Escalators.

Date: -

To,

Subject :

With ref. to Letter No._____________Dated___________ of your office granting

permission to install a Lift at the above mention premises, I / we have state the work of

installation of Lift / Escalator has been completed on .

I / We there for request that a license for operating Lift may be granted.

The work of erection of Lift has been carried out in accordance with the provisions of the

Gujarat Lifts and Escalator Rules, 2001.

A Fee of Rs.1500/-, in accordance with the rule 16 has been paid and the Challan in original is

enclosed.

Yours faithfully,

Signature of the owner/applicant

The Chief Inspector of Lifts and Escalators,

Installations of Lift at:

ANNEXURE V

(See rule 5)

Declaration from the person authorized under section 13

Date: _________

To,

Dear Sir,

We ____________________ having under taken the work of installation the Lift at the

premises named______________________________________________________________________

and having completed the installation of said the Lift hereby certify that the work of

installation of the lift complies with the provisions of the Gujarat Lift and Escalator Rule,

2001. We further Certify that the Lift installation is ready for inspection which is required to

be made for the purpose of issuing under the Gujarat Lift and Escalator Rule, 2000 for

Operating the same.

Date: - Signature of the authorized person.

Authorization number:_____

The Chief Inspector of Lifts and Escalators,