SITE INFORMATION SHEET

SITE IDENTIFICATION
Site Candidate
Site ID
(A/B/C etc.)
Name of Site Candidate
Site Address
Kelurahan
Kecamatan
Kabupaten / Kotamadya
Post Code

City/Province

Visit date
Nominal Longitude
Nominal Latitude ASL :
M
Search Radius Meters
GPS Surveyed Longitude (WGS
84)
GPS Surveyed Latitude (WGS
84)

Distance from Nominal meters ASL : M

Survey route (describe how to find

site)
Residential
Royal / VIP Est. Bldg. Roadside
Gov’t. Est. Commercial Bldg Agricultural Area
Site Area/Location Education Est. Industrial Bldg. Non-Agri. Area
Health Est. Mountain Area Green Field (Plot)
Military Est. Earthquake Others:
area
Exist.
New Greenfield Greenfield Indoor/In-
New Rooftop Exist. Rooftop Building Ex.
Site Type (Height of the roof) (Height of the Indoor/In-Bldg
roof)_________ Others:
New Microcell _______________
Exist. Microcell
Self Support
Tower Pole Mount Mini Tower
Antenna Support
Wall Mount Others:
Monopole Tower
 New
Tower / Pole Height (m) &
M Share
Type
Existing
New CKD Shelter Existing
Sun Shelter
Equipment Housing New Permanent Shelter
Others:
Shelter Leased Room
Equipment Ground near building Ground near Other (17 floor)
room/Shelter Rooftop indoor tower
Rooftop outdoor Ground near tower
location:
Equipment Room Concrete Shelter CKD Shelter Other
Type: Existing room No Shelter
Land Condition: Very Good Good OK Bad Very Bad

Roof Condition: Very Good Good OK Bad Very Bad

Access Road Very Good Good OK Bad Very Bad
Condition
Type of Survey Macro new Site Micro new Site Switch & Node B
Power Source PLN Generator Others
Access Road (m): x M Power Run (m) Acc M
Other Information:

OWNER & ACCESS DETAILS

Property owner

Address
Kelurahan
Kec.
Kab.
Prop.
Telephone No./HP./Fax
Person responsible for access to the site

Address
Kelurahan
Kec.
Kab.
Pro
Telephone No./HP./Fax Hp
Single owner Corporation Other
Type of Ownership: Master Agreement Site Community
Government Partnership
 10 hours
Access Time for Work

Notice for Access Yes No

If Yes, specify time / details?

Any times

Length x
Land / Rooftop Area x Area (m2)
Width (m)

Length x
Private Access x
Width (m)
Lease 10 Years Can be Yes
Acquisition Type (min)
Buy extended No

Lease Price / year IDR / Years

Payment Method Transfer by bank
Total Lease Price IDR
LEASE

Leasing Procedures Present of Notary Without Notary

PPh….Tax Included PPh …… Tax Not Included

Lease Price
condition
Notary Fees Included Notary Fees Not Included

Buy Price / m2 IDR.

Total Price IDR.

BUY

PPAT Fees Included PPAT Fees Not Included

Buy Price
conditions
BPHATB 5% Included BPHATB 5% Not Included

Transaction terms PLN Power Included PLN Power Not Included

Girik/Persil No.
Land Ownership
Certificate No.
documents
SPPT/PBB No.

Akte Jual-Beli No.

Others

Permits Required
RT/RW Tata Kota (RUTR) IMB

Kelurahan Bapeda Community

Kecamatan Hub Tel Socialization
 Other:

Government Permits OK Not OK

Permits Possibilities
Community Permits OK Not OK

Comments

Any Environmental or Cultural problems? Yes No

If yes describe the problem, contact person,
time and procedure to resolve
Any Aviation problems? Yes No
If yes describe the problem, contact person,
time and procedure to resolve
Any Military problems? Yes No
If yes describe the problem, contact person,
time and procedure to resolve
Other Information:
MAP CAPTURED

(Insert nominal pointer and candidate pointer at elevation on map 5 km)