MINISTERUL SNTII

DIRECIA DE SNTATE PUBLIC A MUNICIPIULUI BUCURETI

____________________________________________________________________________________

Adresa: str. Avrig nr.72-74, sector 2, Bucureti Romnia

Tel: 021.252.79.78; 021.252.32.16/ Fax: 021.252.55.20
Site: www.dspb.ro/ e-mail: dspb@dspb.ro

Biroul Avize - Autorizri

Tel: 021.314.93.57; Tel: 021.252.79.78- int.115 ; e-mail: avize@dspb.ro

CERERE

Subsemnatul(a), ............................................................................................................,cu domiciliul

n
localitatea
......................................................
sector/judeul..........................................
str. .......................................................................................nr.........., bl..........sc........et........ap......... .
posesor/posesoare al/a BI/CI seria ........... nr. ....................., eliberat de ..................................... la data
de
.........................,
n
calitate
de
..........................................................................
al ................. .............................................................................................................................................
,
cu
sediul
n
..................................str......................................................................nr.......l..........sc........ap.......sector/
judet...........................telefon ..............................., fax..................................., nmatriculat la registrul
comerului sub nr. ........................................, avnd codul fiscal nr. ..............................
din ............................, solicit,

autorizatia sanitara in baza declaratiei pe propria raspundere

pentru
.................................................................................................................................................,
situat la (adresa): .......................................................... .....................................................................
avnd ca obiect de activitate (cod CAEN):................................................. ................. .....................
............................................................................................................................................................
structura funcional: ..................................................................................................................... .
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
Anexez la cerere documentaia solicitat, complet, i anume:
a) memoriul tehnic
b) planul de situatie cu incadrarea in zona
c) schie cu detalii de structur funcional i dotri specifice profilului de activitate
d) actul de infiintare al solicitantului
e) acte doveditoare priviind deinerea legal a spaiului
f) declaraia pe propria rspundere semnat, dup caz, de managerul unitii /administrator
i/sau titularul activitii
Documentele mentionate la lit. a) e) vor fi depuse in original sau in copie cu mentiunea
conform cu originalul si vor fi semnate si stampilate de catre solicitant

Data ......../........./...............

Semntura .......................

MINISTERUL SNTII
DIRECIA DE SNTATE PUBLIC A MUNICIPIULUI BUCURETI
____________________________________________________________________________________

Adresa: str. Avrig nr.72-74, sector 2, Bucureti Romnia

Tel: 021.252.79.78; 021.252.32.16/ Fax: 021.252.55.20
Site: www.dspb.ro/ e-mail: dspb@dspb.ro

Biroul Avize - Autorizri

Tel: 021.314.93.57; Tel: 021.252.79.78- int.115 ; e-mail: avize@dspb.ro

* Cerere ASF in baza declaratiei pe propria raspundere