Survey Request

PERMOHONAN SURVEY
APPLICATION FOR SURVEY

KEPADA
BIRO KLASIFIKASI INDONESIA
NOMOR
TO
NUMBER
TANGGAL
DATE
DENGAN INI, KAMI MOHON KEHADIRAN SURVEYOR BIRO KLASIFIKASI INDONESIA DI KAPAL UNTUK MELAKSANAKAN SURVEY KAPAL BERIKUT:
HEREWITH, WE REQUEST SURVEYOR OF BIRO KLASIFIKASI INDONESIA ATTENDINGON BOARD TO CARRY OUT SURVEY(S) FOR THE FOLLOWING SHIP:
NAMA KAPAL
NOMOR REGISTER
SHIPS NAME
REGISTER NUMBER
BENDERA
FLAG
PEMILIK / MANAJER
NOMOR IMO :
IMO PERUSAHAAN
IMO NUMBER
IMO COMPANY
TANDA PANGGILAN
OWNER / MANAGER
CALL SIGN
KLASIFIKASI
TEMPAT & TANGGAL SURVEY
CLASSIFICATION
CALL SIGN
Survey yang harus dilaksanakan

Survey to be carried out
1 Survey Penerimaan Klas

Admission to Class survey
Survey Penerimaan Kelas Bangunan Baru

Admission to Class Survey for new Construction
Survey Penerimaan Kelas Kapal Sudah Jadi

Admission to Class Survey for Ship in Service
Dari Anggota IACS
Dari Klas yang diakui
Dari SelainAnggota IACS dan Selain Klas yang diakui
From IACS Member
From Recognized Class Society
From Non IACS Member and Non Recognized Class Society
Terapung
Diatas Dok
Lain-lain
Afloat
On Dry Dock
Others
2 Survey Periodik dan Survey yang lain

Periodical Survey and other surveys
Survey Pembaruan Kelas
Survey Antara
Survey Tahunan
Class Renewal Survey
Intermediate Survey
Annual Survey
Lengkap No.
Lengkap
Survey Penambatan
Complete No.
Complete
Laid Up Survey
Dimulai No.
Dimulai
Survey Bersambung Lambung
Commence No.
Commence
Continuous Hull Survey
Parsial
Parsial
Survey Bersambung Mesin
Partial
Partial
Continuous Machinery Survey
Survey Penerimaan Kelas Kembali
Survey Poros Baling-baling
Re-class Survey
Survey Instalasi Pendingin
Propeller Shaft Survey
Refrigerating Survey
Survey Perpanjangan Kelas
Survey Normal
Survey Ketel/ Pemanas Minyak Panas
Extention for Class Survey
Normal Survey
Boiler Survey / Thermal Oil Heater Survey
Survey Pengedokan
Survey Modifikasi
Docking Survey
Modified Survey
Penundaan Survey Ketel/Pemanas Minyak

Panas
Survey Bawah Air Pengganti Dok
Survey Parsial
Survey Khusus Lambung
In-water Survey in lieu of docking
Partial Survey
Hull Occasional Survey
Postponement for Boiler/Thermal Oil Heater Survey
Penundaan Survey Pengedokan
Penundaan Survey Poros Baling-baling
Survey Khusus Mesin
Postponement for docking Survey
Postponement for propeller shaft Survey
Machinery Occasional Survey
3 Survey Statutoria
Statutory Survey
Konvensi
Non-konvensi
Convention
Non-convention
Survey Item (s)
CAS
NS
INITIAL
JENIS SURVEY
Kind of Surveyii
ES
RS
AS
IS
PS
OS
F11.1.01-2014/Rev.3
LL
SC
SE
SR
DG
OP
SP
AP
GS
CM
NL
AF
HS
SPS
CAP
CG
KAMI SETUJU UNTUK MEMBAYAR SELURUH BIAYA SURVEY DAN BIAYA LAINNYA YANG TIMBUL TERKAIT DENGAN PELAKSANAAN SURVEY INI
SESUAI SYARAT DAN KETENTUAN YANG BERLAKU DI BIRO KLASIFIKASI INDONESIA
WE AGREE TO PAY ALL SURVEY(S) FEE AND EXPENSES INCURED REGARDING THIS SURVEY ACCORDING TO BIRO KLASIFIKASI INDONESIA TERMS
AND CONDITIONS
PEMOHON
APPLICANT
PERUSAHAAN
COMPANY
ALAMAT
ADDRESS
TANDA TANGAN / STEMPEL

SIGNATURE / STAMP
Review of Application for Survey (Filling by Internal BKI)

Date of receipt :
H
Surveyor in
M
Charge
E
#
Check items
Possible to Carry out by this Location
To be supported by Head Office
To be requested to other class
The survey status confirmed
Complied with class rules or statutory requirements
Each item on the application confirmed
Relevant documents for the survey(s) prepared
Survey Fee (Biaya Survey)
a.
Additional Fee (Biaya Tambahan Diluar Biaya Survey) :
b.
Travelling Expenses (Biaya Perjalan Dinas / Peraturan BKI)
iii
Visit Fee (Biaya Kunjungan) :
o Travel / Waiting :
o Additional outside working hour (diluar jam kerja)
SPS No :
Rp.
Rp.
Total
#
Check X as applicable
as not applicable
Rp.
Rp.
Rp.
Review by..............................
(Signature Head of Job Location)

(After review and sign sending back to applicant)
(By Client / Customer)

Dengan ini kami menyetujui biaya survey yang disampaikan diatas
Nama
Jabatan
Perusahaan
Approved by..............................
(Tanda Tangan & Tanggal)
Catatan / Note:
Biaya atas jasa BKI harus dibayar sesuai dengan tarif BKI dan membebankan juga biaya apa saja yang timbul sehubungan dengan pelayanan
jasa tersebut (misalnya biaya perjalanan, pajak dan biaya-biaya lainnya) walaupun Kelas atau Sertifikat tidak diberikan.
For services rendered by BKI fees are to be paid in accordance with the BKIs Tariffs of Fees, even if no classification is granted. In addition to these
fees, BKI will charge for any expenses incurred in connection with the services rendered.
Jatuh tempo untukpembayaran biaya semua jasa yang diberikan oleh BKI tanpa pengurangan tidak lebih dari 28 (dua puluh delapan) hari
kalender setelah invoice diterima. BKI berhak tidak memenuhi permintaan survey berikutnya, menahan sertifikat dan dokumen lainnya atas
kegagalan memenuhi ketentuan di atas.
The fees for all services rendered by BKI are due for payment without deduction not later than 28 (twenty eight) calendar days after the date of received
invoice. On default BKI entitled to withhold next survey, Certificate and other documents.
BKI bertanggung jawab untuk kerugian atau kerusakan, jika dapat dibuktikan bahwa kerugian dihasilkan langsung dari tindakan atau
kelalaian yang dilakukan BKI. Pertanggung jawaban BKI dibatasi maksimum sebesar biaya survey terakhir yang dilakukan.
BKI will be liable for loss or damage, if it proved that the loss resulted directly from an act or omission of BKI done. The liability of BKI shall be limited in
its amount up to maximum of the fee for that particular service.
Pemohon harus mengisi data dengan sebenar-benarnya pada kolom isian. BKI tidak bertanggung jawab atas segala informasi yang diisikan
pada permohonan ini.
Applicant shall fill in the correct data into the blank spaces. BKI shall not be held responsible for any incorrect data inserted to this application.
i
CAS : Condition Assessment Scheme, LL : Load Line , SC : Safety Construction, SE : Safety Equipment, SR : Safety Radio, DG : Dangerous Good, OP : Oil Pollution
Prevention, SP : Sewage Pollution, AP : Air Pollution, GS: Gas Carrier, CM : Chemical Tanker, NL : Noxious Liquid Substance, AF : Anti Fouling System, HS : High Speed
Craft, SPS : Special Purpose Ship,CAP : Condition Assessment Program , P : Passenger Ship
ii
NS: Initial Survey of Ship During Construction, ES : Initial Survey of Existing Ship, RS : Renewal Survey, AS : Annual Survey, IS : Intermediate Survey, PS : Periodical Survey,
OS : Occasional Survey, CG : Cargo Gear
iii
Travel / Waiting : Rp. (Agar Diisi Dengan Nilai Baku Sesuai Buku Tarif BKI)
Survey Dijam kerja : Rp. (Agar Diisi Dengan Nilai Baku Sesuai Buku Tarif BKI)
Survey Diluar Jam Kerja : Rp. (Agar Diisi Dengan Nilai Baku Sesuai Buku Tarif BKI)
Hari jam kerja BKI adalah (senin s/d Jumat jam 08.00 s/d 17.00 waktu setempat
BKI akan melaksanakan survey jika biaya survey tersebut diatas telah mendapat persetujuan dari pemohon.
F11.1.01-2014/Rev.3

Survey Request

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PERMOHONAN SURVEY

APPLICATION FOR SURVEY

BIRO KLASIFIKASI INDONESIA

TEMPAT & TANGGAL SURVEY

Survey yang harus dilaksanakan

1 Survey Penerimaan Klas

Survey Penerimaan Kelas Bangunan Baru

Survey Penerimaan Kelas Kapal Sudah Jadi

Dari Anggota IACS

Dari Klas yang diakui

Dari SelainAnggota IACS dan Selain Klas yang diakui

From IACS Member

From Recognized Class Society

From Non IACS Member and Non Recognized Class Society

2 Survey Periodik dan Survey yang lain

Survey Pembaruan Kelas

Class Renewal Survey

Survey Bersambung Lambung

Continuous Hull Survey

Survey Bersambung Mesin

Continuous Machinery Survey

Survey Penerimaan Kelas Kembali

Survey Poros Baling-baling

Survey Instalasi Pendingin

Propeller Shaft Survey

Survey Perpanjangan Kelas

Survey Ketel/ Pemanas Minyak Panas

Extention for Class Survey

Boiler Survey / Thermal Oil Heater Survey

Penundaan Survey Ketel/Pemanas Minyak

Survey Bawah Air Pengganti Dok

Survey Khusus Lambung

In-water Survey in lieu of docking

Hull Occasional Survey

Postponement for Boiler/Thermal Oil Heater Survey

Penundaan Survey Pengedokan

Penundaan Survey Poros Baling-baling

Survey Khusus Mesin

Postponement for docking Survey

Postponement for propeller shaft Survey

Machinery Occasional Survey

Survey Item (s)

TANDA TANGAN / STEMPEL

Review of Application for Survey (Filling by Internal BKI)

(Signature Head of Job Location)

(By Client / Customer)

(Tanda Tangan & Tanggal)

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