formulir izin prinsip__parasuma.doc.docx
TRANSCRIPT
-
8/18/2019 FORMULIR IZIN PRINSIP__PARASUMA.doc.docx
1/7
LAMPIRAN I-APERATURAN KEPALA BADAN KOORDINASI PENANAMANMODAL REPUBLIK INDONESIA NOMOR 5 TAHUN 2013TENTANG PEDOMAN DAN TATA CARA PERIZINAN DANNONPERIZINAN PENANAMAN MODAL
PERMOHONAN IZIN PRINSIP/IZIN PRINSIP PERLUASAN PENANAMAN MODAL
I. KETERANGAN PEMOHON
A. Diisi ole !e"oo# $%#& BELUM 'e('%)%# *+*" I#)o#esi%
1. N%"% Pe"oo# , T*%# -EE CHEE PANG%. Al%"% , No. 12 /l# 155A B*+i OUG To#
Ho*se K*%l% L*"!*( 4es M%l%$si%
5200b. E-mail , 2. N%"% Pe(*s%%%# $%#& A+%#
Di'e#*+
, PT. PARASUMA CONSTRUCTION
%. Al%"% Ko(es!o#)e#si , /l. 4%le( Mo#&o#si)i No. 6 7
Ke'%$o(%# B%(* Peo&o&%# /%+%(%
Sel%%# Ko)e Pos 12180'. Tele!o# , 021839682:. 7%+si"ile , 0218203593). E-mail , ;i%. 1? RT.
010R4. 005 Kel. Te'e B%(% Ke:. Te'e /%+%(%
Sel%%# 1210'. Tele!o# , 021 31 0212:. 7%+si"ile , 021 31 0218). E-mail , ;i%
-
8/18/2019 FORMULIR IZIN PRINSIP__PARASUMA.doc.docx
2/7
?. D%% Pe(ii#%# Pe(se*;*%# Pe#%#%"%# Mo)%l $%#& el% )i"ili+i
N
o
Nomor dan Tgl
Periinan/
Per!e"#$#an
Lo%a!i
Pro&e%
'idang
U!a(aSa"#an
Ka)a!i"a!
Prod#%!i
L#a!
Tana(
*m+/(a,
Tenaga
Ker$a
Indone!ia
Orang
*L/P,
Ine!"a!i
*US/R),
1 No"o( ,255TI#)*s(i 2003
K%%s%#
I#)*s(i
K(%+%%*
Cile&o#
B%#e#
K%'el
Se%
O!i+
To# 1.200 15.000 82 15.?50.000
/*"l% 1.200 15.000 82 15.?50.000
II. KETERANGAN RENANA PENANAMAN MODAL
1. Bi)%#& Us%% , Ge#e(%l Co#(%:o(Co#s(*:io#2. Lo+%si P(o$e+ ,
%. Al%"% , /l. 4%le( Mo#&o#si)i No. 6 7
Ke'%$o(%# B%(* Peo&o&%#'. K%'*!%e# Ko% , /%+%(% Sel%%#:. P(o>i#si , DKI /%+%(%
3. P(o)*+si )%# Pe"%s%(%# Pe( T%*# ,
0eni! 'arang/0a!a K'LI Sa"#an Ka)a!i"a!E%!)or
*1,Ke"erangan
2. 0a!a Kon!"r#%!i *0a!a
Pela%!ana Kon!"r#%!i, $%#&
Me#&&*#%+%# Te+#olo&i Ti#&&i
)%#%%* Risi+o Ti#&&i
)%#%%* Nil%i Pe+e(;%%# Le'i)%(i R!. 1.000.000.000,
Pe+e(;%%# Ko#s(*+si *#*+
'%#&*#%# G*)%#& %%*
I#)*s(i P%'(i+ Pe+e(;%%# Ko#s(*+si *#*+
'%#&*#%# Ko"e(si%l Pe+e(;%%# Ko#s(*+si *#*+
'%#&*#%# S%(%#% Kese%%# Pe+e(;%%# Ko#s(*+si *#*+
'%#&*#%# S%(%#% Pe#)i)i+%# Pe+e(;%%# Ko#s(*+si *#*+
'%#&*#%# Hoel Reso(%#
61013
61016
61015
6101?
61018
-
8/18/2019 FORMULIR IZIN PRINSIP__PARASUMA.doc.docx
3/7
)%# Se;e#is#$% Pe+e(;%%# Ko#s(*+si *#*+
'%#&*#%# S%(%#% Hi'*(%#
U"*" Pe+e(;%%# Ko#s(*+si *#*+
'%#&*#%# L%i##$% Pe+e(;%%# Beo#
Pe+e(;%%# Ko#s(*+si *#*+,/%l%# R%$% @+e:*%li /%l%#
L%$%#&/%l%# Ke(e% A!i)%# L%#)%s%# P%:* Pes%%
Te('%#& Pe+e(;%%# *#*+ Ko#s(*+si
/e"'%%# /%l%# L%$%#&
Te(oo#&%# )%# /%l%# B%%
T%#% Pe+e(;%%# Ko#s(*+si *#*+
/%l*( Pi!% Ai( T(%#s"isi/%(i#&%# Tele+o"*#i+%si )%#
/%(i#&%# Lis(i+ @K%'el Pe+e(;%%# Pe"'o(o#&%#
*#*+ Ge)*#& Be(i#&+%
Le'i )%(i D*% L%#%i Pe+e(;%%# G%li%#
Pe"i#)%%# )%# Ti"'*#%#
T%#% Pe+e(;%%# Pe(si%!%# *#*+
L%%# Pe(%"'%#&%# Pe+e(;%%# Pe"'e(si%# )%#
Pe#$i%!%# L%!%#&%# Pe+e(;%%# Ko#s(*+si Al%("
Ke'%+%(%# Pe+e(;%%# Ko#s(*+si Al%("
Pe#:*(i%# Pe"'*%%# s*"*( Ai( Pe+e(;%%# Ko#s(*+si
Pe(!i!%%# G%s Pe+e(;%%# Ko#s(*+si Li )%#
Es+%l%o( Pe+e(;%%# Pe"%s%#&%# K%:%
/e#)el% I#s%l%si Ge)*#& L%i##$% Pe+e(;%%# Pe"%s%#&%#
Ke(%"i+M%("e( Di#)i#& )%#
6101
61019
610206212062220
62111
6211362116
6211262115
62219
63221
63110
63120
63120
63120
63218
63218
6321
63223
63291
63301
63299
63302
-
8/18/2019 FORMULIR IZIN PRINSIP__PARASUMA.doc.docx
4/7
L%#%i Pe+e(;%%# Pel%!is%# Di#)i#&
)%# L%#%i L%i##$% Pe+e(;%%# Plese(%# Pe+e(;%%# Pe#&e:%%# Pe+e(;%%# De+o(%si I#e(io(
Pe+e(;%%# O(#%"e# Pe+e(;%%# A+i( )%# Pe(%!i%#
L%i##$% Pe+e(;%%# P%s%#&%# B%* K%li Pe+e(;%%# Pe"'esi%# Pe+e(;%%# Pe(%#:% )%#
Be+isi#& Pe+e(;%%# A%! )%#
Pe#:e&%%# Ke'o:o(%# /%s% Pe#$e%%# Pe(%l%%#
*#*+ Pe+e(;%%# Ko#s(*+si
%%* Pe"'o(o#&%# )e#&%#
O!e(%o( Pe+e(;%%# Ko#s(*+si K*s*s
L%i##$% ,• Pe+e(;%%# K%$* )%#
R%#&+% Lo&%"• Pe+e(;%%# Isol%si @K%'el
Lis(i+ Ai( Pe"%#%s )%#
S*%(%• Pe+e(;%%# Pe"%s%#&%#
K%'el )%# 7ii#& Lis(i+• Pe+e(;%%# Pl*"'i#&
@Pe+e(;%%# D(%i#
e("%s*+ "e#$i%!+%#
!e"'*%#&%# %i( +oo(• Pe+e(;%%# Pe"%s%#&%#
Pe(%l%%# Pe"%#%s
e#il%si )%# Pe#&%*(
S** U)%(%• Pe+e(;%%# Ko#s(*+si
Lis(i+ L%i##$%• Pe+e(;%%# I#s%l%si
L%i##$%• Pe+e(;%%# I#s%l%si
L%i##$% -%#& Ti)%+
Di+l%sii+%si+%# )i Te"!%
L%i# Pe+e(;%%# Pe#&*+*(%# )%#
Pe#&*;i%# L%!%#&%#
63302
63302
63302
63306
6330563309
63901
639016390263902
63903
63905
63909
-
8/18/2019 FORMULIR IZIN PRINSIP__PARASUMA.doc.docx
5/7
81100
+. 0a!!a 'i!ni!/0a!a Kon!#l"an!i
Kon!"r#%!i /%s% P(%)es%i# )%#
Ko#s*l%#si A(sie+*( /%s% Des%i%# A(sie+*( /%s% A)"i#is(%si Ko#(%+ /%s% Des%i# A(sie+*( )%#
A)"i#is(%si Ko#(%+ /%s% A(sie+*( L%i##$% /%s% Re+%$%s% Des%i#
Ko#s(*+si *#*+ Po#)%si )%#
S(*+*( B%#&*#%# /%s% Re+%$%s% Des%i#
Ko#s(*+si *#*+ Pe+e(;%%#
Te+#i+ Si!il /%s% Re+%$%s% sel%"%
Ko#s(*+si )%# Pe"%s%#&%#
I#s%l%si Li##$% /%s% Re+%$%s% sel%"%
Ko#s(*+si )%# Pe"%s%#&%#
L%i##$%
/%s% Re+%$%s% Te(!%)* *#*+!(%s%(%#% T(%#s!o(%si
/%s% Re+%$%s% Te(!%)* )%#
M%#%;e"e# P(o$e+ Ai( )%#
S%#i%si )e#&%# Sise"
Te(i"% /%)i /%s% Re+%$%s% Te(!%)* *#*+
Ko#(*+si P(o$e+ P%'(i+%si
)e#&%# Sise" Te(i"% /%)i /%s% Re+%$%s% Te(!%)* *#*+
P(o$e+ P%'(i+%si )e#&%#
Sise" Te(i"% /%)i L%i##$% /%s% Pe(e#:%#%%# Ko% /%s% A(sie+*( Pe(%"%#%# /%s% Pe#&*;i%# )%# A#%lis%
Ko"!osisi )%# Ke"*(#i%#
'%(%#&'%(%#& 7isi+ /%s% Pe#&*;i%# )%# A#%lis%
%%s Sise" Me+%#i+ Te(!%)* Sise" I#s!e+si Te+#is /%s% Pe#&*;i%# )%# A#%lis%
L%i##$%
81100
81100
8110081100
81100
81100
81100
81100
81100
81100
81100
811008110081100
81100
8110081100
KL 2.000 KL U#*+ Ke!e(l*%#
L%'o(%o(i*"
0a!a Di!"ri3#"or U"ama
-
8/18/2019 FORMULIR IZIN PRINSIP__PARASUMA.doc.docx
6/7
'%(%#& )%&%#&%#%l%%l% 'e(% )%# +o#s(*+si
%.l , (%+o( e:%>%o(
'*ll)oe( :(%#e lo%)e(
(olle( &e#se e:%>%o(
eel lo%)e( '%:+oelo%)e( '*ll)oe( :o"!%:o(
&(%)e( !%>e( %s!%l "ii#&
!l%# :(%le( :(%#e "o'ile
:(%#e (o*& e((%i#
:(%#e lo(($"o*#e)
:(%#e (o%($ )(illi#& (i&
s%i: !ile )(i>e( )i%!(%&"
%ll &(%' >i'(o %""e(
:o#:(ee !*"! (*:+ (%ile(
"o*#e) :o#:(ee !*"!
:o#:(ee "ie( (*:+
:o#:(ee '%:i#& !l%#
:o#:(ee !l%:i#& 'oo"
)*"!i#& (*:+ o(o%)
(*:+ o(+li (e%: s%:+e(
:o#%i#e( %#)le( $%()
:(%#e si!oso(e :(%#e.
Pe(+i(%%# Nil%i E+s!o( !e( %*# , USF 200.000006. L*%s T%#% $%#& )i!e(l*+%# , 3.000 "2
5. Te#%&% Ke(;% I#)o#esi% , ?5 O(& @ 50 L 15 P ?. Re#:%#% Nil%i I#>es%si ,
% Mo)%l Te%! Pe"'eli%# )%# Pe"%%#&%# T%#% , R!. 1.00.000.00000 B%#&*#%# Ge)*#& , R!. 2.885.000.00000 Mesi#Pe(%l%%# )%# S*+* C%)%#& , R!. 3.500.000.00000 T(%#s!o(%si , R!. 000
L%i#l%i# , R!. 1.000.000.00000S*' /*"l% , R!. 9.085.000.00000
' Mo)%l Ke(;% @*#*+ 1 *(# o>e( , R!. 6.000.000.00000/*"l% @% ' , R!. 13.085.000.00000
8. Re#:%#% Pe("o)%l%# ,
% S*"'e( Pe"'i%$%# Mo)%l Se#)i(i , R!. 6.000.000.00000 L%'% )i%#%" +e"'%li , R!.
Pi#;%"%# , R!. Pi#;%"%# L*%( Ne&e(i , R!. Pi#;%"%# D%l%" Ne&e(i , R!. 9.085.000.00000/*"l% , R!. 13.085.000.00000
-
8/18/2019 FORMULIR IZIN PRINSIP__PARASUMA.doc.docx
7/7
. Pe#$e(%%# D%l%" Mo)%l Pe(se(o%#No. Pe"e&%#& S%%" Al%"% )%# Ne&%(% As%l Nil%i No"i#%l S%%"
Pese(% Asi#&1.2.Pese(% I#)o#esi%
1.2
III. PERN4ATAAN
B%% s%$% #%"% , SU4ND- TASMADI )%l%" +%!%si%s s%$% se'%&%i Pi"!i#%# Pe(*s%%%#PT. SMART LAB INDONESIA )e#&%# i#i "e#$%%+%# ,
1. A!%'il% )%l%" !el%+s%#%%# !e#%#%"%# "o)%l i#i )i +e"*)i%# %(i"e#i"'*l+%# )%"!%+ #e&%i e(%)%! "%s$%(%+% )%# li#&+*#&%# i)*!Pe(*s%%%# 'e(se)i% "e"i+*l se&%l% %+i'% $%#& )ii"'*l+%# e("%s*+ !e#&&%#i%#+e(*&i%# +e!%)% "%s$%(%+%
2. S%$% "e#$%%+%# '%% !e("oo#%# i#i )i'*% )e#&%# 'e#%( )i%#)%%#&%#i ole$%#& 'e(%+ )i %%s "ee(%i $%#& :*+*! )%# s%$% "e#$%%+%# '%% s%$%
"e#;%"i# )%# 'e(%#&&*#& ;%%' se:%(% *+*" %%s ,%. Ke%sli%# sel*(* )o+*"e# $%#& )is%"!%i+%#'. Keses*%i%# sel*(* (e+%"%#oo+o!i )%% $%#& )is%"!%i+%# )e#&%# )o+*"e#
%sli#$% )%#:. Ke%sli%# sel*(* %#)%%#&%# $%#& e(:%#*" )%l%" !e("oo#%#.
/%+%(% 2 Mei 2013
-%#& "e"'*% !e(#$%%%#PT. SMART LA' INDONESIA
M%e(%i R!. ?.00000
SU5AND4 TASMADIDi(e+*(