Form XXX

[See Rule 162]

CERTIFICATE OF STABILITY

1. Name of the factory....................................................

2. Village, town and district in which the factory is

situated....................................................

3. Full postal address of the

factory....................................................

4. Name of the occupier of the

factory....................................................

5. Name of manufacturing process to be carried on in the

factory............................

6. Number of floors on which workers will be

employed............................

7. Material of construction. Walls, roof, etc.

8. Number of buildings/structures, give details:

(a) Constructed area on the ground floor

(b) Total Constructed area and height of each floor

9. Tests were applied:

(a) Rebound Hammer test

(b) Ultrasonic pulse velocity test

(c) any other tests; namely ....................................................

10. Details of examination of steel structures and sheet roofing:

(a) High raised chimney: state if it is self-supported or tied by

tensioning ropes; are the tensioning ropes/ foundation fastening

safe and in good condition?

(b) Observation regarding steel structures, if any:

(c) Observation regarding the stability of sheet roofing; if provided:

11. Defects/ requirement of repair if any:

This is certified that I have inspected the building/buildings, the plans of

which have been approved by the Chief Inspector cum facilitator in his

letter No.............. dated............ and examined the various parts,

including the foundations with special reference to the machine, plant,

etc., that have been installed. I am of the opinion that the

building/buildings which has/have been

constructed/reconstructed/extended/taken into use is/are in accordance

with the plans approved by the Chief Inspector in his letter mentioned

above, that it/they is/are structurally sound and that its/their stability will

not been endangered by its/their use as a factory/part of a factory for the

manufacture of........... for which the machinery, plant, etc. installed are

intended.

Signature...............................................

Qualification...........................................

Address.................................................

Date.....................................................

Certification No........ date................. of competency issued by Chief

Inspector cum facilitator. If employed by a company or an association,

the name and address of the company or association.