Form Survey Bangunan 070917.docx

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA

A.

DATA UMUM/ GENERAL DATA

1. NAMA / NAME Nama bangunan/properti Name of building/property

2. LOKASI / LOCATION Alamat Address No. telepon/email/website Kelurahan Kota Provinsi Kode Pos Koordinat (lintang utara selatan, bujur timur barat) 3. KEPEMILIKAN / OWNERSHIP Nama lengkap pemilik /institusi yang dapat dihubungi/ Contact person – applicant’s name Nomor telepon dan email kontak/ Phone & e-mail of applicant

Jabatan/posisi (pemilik, penyewa, pengelola, arsitek, kontraktor, dll)/ Applicant’s position

Status kepemilikan bangunan & tanah (milik sendiri, sewa, dll). Nama orang/ institusi pemilik bangunan. Building and site/land ownership status Name of owner/institution Prepared by PDA (28/07/17) 1

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA

B.

DATA STATUS CAGAR BUDAYA/ STATUS OF HERITAGE LIST

1. STATUS CAGAR BUDAYA / STATUS OF HERITAGE LIST Apakah bangunan/obyek berstatus  belum cagar budaya cagar budaya/  Diduga cagar buday (sudah terdaftar oleh TACB/BPCB/dll) Status of heritage list  Cagar budaya No. Penetapan cagar budaya: …………………………………………….. 2. STATUS CAGAR BUDAYA / STATUS OF HERITAGE LIST Tingkat status cagar budaya/  Kota/Kabupaten Level of heritage  Provinsi  Nasional 3. STATUS PELESTARIAN / STATUS OF CONSERVATION Apakah bangunan pernah dipugar  Belum sebelumnya/ Status of conservation  Sudah Berapa kali …….. Tahun berapa …….. Tindakan pelestarian yang pernah  Pemugaran (rehabilitasi, restorasi, renovasi, dsb) dilakukan / conservation works that  Adaptasi (penambahan elemen baru) have done  Revitalisasi Boleh dipilih lebih dari satu Deskripsi tindakan pelestarian / Uraian singkat (misalnya perbaikan atap, perbaikan dinding, description of conservation works dsb)

C.

DATA LINGKUNGAN SEKITAR / DATA OF SURRONDING NEIGHBORHOOD

1. KAWASAN CAGAR BUDAYA / HERITAGE DISTRICT Apakah bangunan berada dalam  belum cagar budaya kawasan cagar budaya/  Diduga cagar buday (sudah terdaftar oleh TACB/BPCB/dll) Does object in the heritage district  Cagar budaya No. Penetapan cagar budaya: …………………………………………….. 2. STATUS CAGAR BUDAYA / STATUS OF HERITAGE LIST Tingkat status cagar budaya/  Kota/Kabupaten Level of heritage  Provinsi  Nasional

Prepared by PDA (28/07/17) 2

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA 3. KARAKTER KHUSUS LINGKUNGAN & SEJARAHNYA / DISTRICT CHARACTER & HISTORY Karakter khusus lingkungan/ Jelaskan dengan singkat karakter khusus/spesifik kawasan. District character Misalnya kawasan pemukiman, kawasan pergudangan, kawasan perdagangan/perniagaan, kawasan pelabuhan, dst.

Sejarah kawasan / History of district

4. BATAS TAPAK / SITE BOUNDARIES Batas tapak / Sisi utara: Site boundaries (batas tapak bisa berupa bangunan, lahan, sungai, jalan, kanal, rel kereta, dsb).

Sisi timur:

Sisi selatan:

Sisi barat

Prepared by PDA (28/07/17) 3

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA

D.

DATA ARSITEKTUR BANGUNAN/ ARCHITECTURAL DATA

1. INFORMASI BANGUNAN / BUILDING INFORMATION Luas tanah (m2)/ Land area Luas Bangunan (m2) / Building area Jumlah massa bangunan / Numbers of object in a site

Jumlah lantai bangunan / building storeys

Jika lebih dari satu sebutkan satu persatu bangunan (nama & fungsi) 1. …… 2. …… 3. Jika lebih dari satu sebutkan jumlah lantai satu persatu bangunan 1. …… 2. …… 3.

2. SEJARAH / HISTORY Sejarah pembangunan & fungsi / Age or phases of construction and function

3. FUNGSI / TYPE OF BUILDING USE Fungsi bangunan saat ini/ Current function of building / type of building use

Prepared by PDA (28/07/17) 4

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA 4. NILAI PENTING / SIGNIFICANCE Nilai penting bangunan (arsitektural, sejarah, konteks kawasan) / Heritage building significance a. Nilai penting arsitektur (bentuk bangunan, langgam, tipologi dan elemen arsitektur) Architecture value (design/style)

b. Sejarah (arsitek/ perancang/ pembangun, tokoh, peristiwa) Historic value

c. Nilai penting dan konteks pada kawasan Urban value

Prepared by PDA (28/07/17) 5

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA 5. KEUTUHAN BANGUNAN/KEASLIAN/PERUBAHAN BANGUNAN / BUILDING INTACTNESS, ALTERATION, ADDITION a. Keutuhan / keaslian bangunan (bagian-bagian bangunan yang masih asli, keseluruhan/ sebagian / elemen yang signifikan) Intactness/Originality/Significant    

Sosok / building form Eksterior / Exterior Denah / Plan Elemen dan material / Elements and Material (pintu, jendela, kolom, lantai, plafond, atap, hiasan, tangga, talang, dll / door, window, column, beam, floor, ceiling, roof ornaments, stairs, gutter, etc)

b. Perubahan/penambahan (penambahan ruang/dinding, penggantian jenis lantai, plafond, pintu jendela, dll) Addition and alteration    

Sosok / building form Eksterior / Exterior Denah / Plan Elemen arsitektur / Architecture Elements (pintu, jendela, kolom, lantai, plafond, atap, hiasan, tangga, talang, dll / door, window, column, floor, ceiling, roof ornaments, stairs, gutter, etc)

Prepared by PDA (28/07/17) 6

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA 6. DATA GAMBAR & FOTO / IMAGES Gambar/ foto/ sketsa bangunan saat ini maupun foto lama, perubahan & penambahan pada bangunan dll. Present/ old picture or drawings. Alteration & addition, etc GAMBAR, SKETSA ATAU FOTO / ANNEX:PHOTO, SKETCHES, DRAWINGS – NO.1

Keteranganfoto/gambar Subject of image Tanggalfoto/gambar Date of image Fotograferatausumber Photographer/author Pemilikcoyright Copyright holder

GAMBAR, SKETSA ATAU FOTO / ANNEX:PHOTO, SKETCHES, DRAWINGS – NO.2

Keteranganfoto/gambar Subject of image Tanggalfoto/gambar Date of image Fotograferatausumber Photographer/author Pemilikcoyright Copyright holder Prepared by PDA (28/07/17) 7

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA GAMBAR, SKETSA ATAU FOTO / ANNEX:PHOTO, SKETCHES, DRAWINGS – NO.3

Keteranganfoto/gambar Subject of image Tanggalfoto/gambar Date of image Fotograferatausumber Photographer/author Pemilikcoyright Copyright holder

GAMBAR, SKETSA ATAU FOTO / ANNEX:PHOTO, SKETCHES, DRAWINGS – NO.4

Keteranganfoto/gambar Subject of image Tanggalfoto/gambar Date of image Fotograferatausumber Photographer/author Pemilikcoyright Copyright holder

Prepared by PDA (28/07/17) 8

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA

E.

KELENGKAPAN DOKUMEN BANGUNAN/ BUILDINGS’ DOCUMENTS

1. DOKUMENTASI & PERENCANAAN BANGUNAN / DOCUMENTATION & PLANNING Penjelasan mengenai pengecekan bangunan, perencanaan dan rekomendasi yang pernah dilakukan. Description of previous building’s assessment, planning and recommendations. Konfirmasi pendaftar / applicant confirmation a. Apakah bangunan sudah pernah diteliti dan dinilai sebelumnya./ Heritage impact assessment status

Sudah Belum Jelaskan pelaksana dan waktu pelaksanaannya.

b. Dokumen gambar eksisting bangunan / Heritage significance documents

 Ada Tidak ada Jika ada, terdiri dari gambar:

c. Apakah bangunan sudah memiliki rencana konservasi/pemanfaatan bangunan Scope of Conservation plan

Sudah Belum Jika sudah, jelaskan lingkup perencanaannya.

(perawatan, pemugaran, adaptasi, program fungsi baru / regular maintenance, moderate/complex conservation, adaptation, new function)

d. Apakah perencanaan melibatkan arsitek/ planner

Ya Tidak Sebutkan nama arsitek/ tim yang terlibat.

e. Dokumen perencanaan/ Documents/ Drawings of Conservation plan

 Ada Tidak ada Jika ada, terdiri dari dokumen perencanaan apa saja:

(dok.rencana perawatan, dok.rencana pemugaran, dok.renc.adaptasi, doc.MEP / doc.maintenance, doc.conservation, doc.adaptation, doc.service-MEP)

2. LAMPIRAN HASIL DOKUMENTASI & PERENCANAAN *Jika ada / ATTACHMENT OF DOCUMENTS (DOCUMENTATION & PLANNING) *if available. Prepared by PDA (28/07/17) 9

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA

F. KONDISI BANGUNAN & IDENTIFIKASI KERUSAKAN/ BUIILDINGS CURRENT CONDITION & IDENTIFICATION OF BUILDING DAMAGES

1. ATAP / ROOF AREAS Item

Kerusakan / Possible Defects

Atap genteng tanah liat / Terracotta tiles

 Bergeser/ melorot, Slipped,  pecah, broken,  retak, cracked,  sambungan metal berkarat, corroded fixings, missing,  bubungan tidak rapi, poor ridge capping,  dll, etc.

Atap Metal / Metal sheet roofing

 Melorot, Loose, corroded  berkarat, corroded fixings  berlubang, holes  sambungan lapuk, deteriorated patches  penyok bekas injakan, dented by foot traffic  air tergenang, water ponding  terdapat bagian yang hilang, missing sections  bukan atap asli not original roof

Besi galvanis, tembaga, seng, alumunium (Galvanized iron, copper, zinc sheeting, aluminum)

Talang Datar & flashing/ Gutters & flashing

 Besi galvanis, Galvanized iron  colorbond – menggunakan dua jenis metal yang tisak sejenis, colorbond, – metals incompatibility  terdapat reruntuhan/ tanaman, Full of debris or vegetation  air menggenang, water ponding from inadequate fall  kapasitas tidak sesuai, failed jointing  sambungan lepas, missing sections  ada bagian yang hilang, corroded or corroded fixings  berkarat, berlubang, holes or splits.

Talang tegak dan boks talang / Downpipes & Rainwater heads

 Tersumbat, Blockage  berkarat, corroded  kapasitas tidak sessuai, inadequate capacity  sambungan lepas, joints failing  pemasangan tidak benar, corroded fixings, inadequate fixings  tekukan terlalu tajam, sharp angle bends  tidak terhubung dengan bak control, not connected to storm water drains

 terdapat bagian yang hilang, missing sections -all or part Perlindungan hewan liar/ Vermin Protection

 JIka terdapat penghalau burung? Any bird proofing?  Tidak berfungsi, not working  secara estetis mengganggu, aesthetically insensitive Prepared by PDA (28/07/17) 10

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA  pemasangan mengaibatkan kerusakan atap. fixing causing damage  Apakah penghalau burung diperlukan? Bird proofing needed?

Papan atap/list-plank & talang / teritisan, sudut pertemuan papan / Timber fascia boards, Eaves, Barge Board, etc

 Cat mengelupas, Peeling paint  kayu lapuk, weathered timber, rot  kayu terlepas, split  terdapat rayap, repainting required  kayu membusuk, evidence of termites,  ada yang hilang, dll missing sections, etc

 Cerobong / Chimney  exhaust / exhaust flues  lubang ventilasi / air vents  jendela dormer / dormer vents  menara ventilasi / dormer windows  finial(ujung atap) /roof lanterns, finials

 Rusak, Damaged  ada yang hilang sebagian/ keseluruhan, missing -in parts or whole  lapuk, rot  berubah bentuk/ dimodifikasi modified, metal or glass missing

Rangka atap / Internal roof structure

 Struktur kayu, lapuk, Timber structure, rot  terdapat bagian yang hilang, missing pieces  rangka baja, steel trusses  terdapat bagian yang hilang, missing members  bracing, bracing  gording, kasau & reng, purlins, battens  balok kuda-kuda dan balok penggantung rangka plafond beams and ceiling hanger beams

2. ELEMEN DINDING LUAR / EXTERIOR ELEMENTS Item Cat & Plesteran / Paint & Render

Kerusakan / Possible Defects  Kopong, Drummy  tidak menempel, detaching  retak, cracked  terkikis, eroded  megelupas, missing sections  menggunakan cat tidak bernafas, non-breathable paints  plesteran menggunakan semen, cement rich render patches and coatings  lembab dan kadar garam tinggi, dampness and salt attack  terdapat tanaman liar, ruptured by vegetation growth  cat menggelembung, bubbling paint  cat berlapis-lapis, multiple paint layers  detil ornament hilang, lost details Prepared by PDA (28/07/17) 11

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA Spesi antar bata / Brickwork Mortar Joints

 Nat spesi terkikis, Open joints  spesi tidak menempel, loose mortar  spesi ditambal semen, hard cement mortar patching  erosi dinding, erosion  spesi tidak ada, missing mortar

Dinding Bata / Brickwork Walls parapets, towers, gables,

 Dinding terkikis, Eroded brick  ada bagian yang roboh, collapsed wall sections  terdapat bata hilang, missing bricks  pelapukan, face weathering  retak, soiling  lembab karena kebocoran, cracked surfaces  lembab karena air tanah, failed or no damp proof course  garam, perbaikan dengan semen rising damp, salt attack, previous cement rich repairs

 tumbuh tanaman liar wild plants Elemen Beton / Concrete elements: Kolom, kanopi, balkon, teritisan, teras, tangga / Columns, canopy, balconies, eaves, porches, stairways, overhangs, etc

 Retak, Cracking  lembab karena air tanah, rising damp  lumut, moss  tulangan berkarat, corroded iron-bars  bocor, leaking  terdapat akar tanaman, plants roots

Batu alam / Stonework Granite, marble, sandstone, andesite,

 Retak, Cracking  delaminasi, delaminating  efek garam, salt affected  lapuk, weathered  detil hilang, loose or loss of detail  ada yang hilang, missing sections  berjamur, biological growth  endapan tanah, soiled by environmental pollutants  kotoran burung, unsympathetic patches  rembesan air, failed or no damp proof course  sambungan/tambalan jelek, bird guano/debris  noda korosi, corroded metal inserts  noda coretan, graffiti  bekas coating lama, corroded metal inserts, previous coatings applied)

Pelapis dinding / Wall tiling

 Retak, Cracking  delaminasi, delaminating  efek garam, salt affected  lapuk, weathered  detil hilang, loose or loss of detail  ada yang hilang, missing sections  berjamur, biological growth  endapan tanah, soiled by environmental pollutants Prepared by PDA (28/07/17) 12

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA  kotoran burung, unsympathetic patches  rembesan air, graffiti  sambungan/tambalan jelek, unsympathetic paint coatings applied

Pintu (yang menghadap luar) / Door

 Kusen/ daun pintu hilang, Missing frames and/ or sashes  kaca hilang, missing glass  kaca dicat, painted shut  pengait daun jendela dll, sash cords  daun pintu macet, pulleys, jammed sashes  kaca pecah, broken glass  dempul pecah/ hilang, defective or missing putty  kusen dan dinding renggang, open/loose joints between wall & timber frame

 kayu lapuk, Weather cracking in timberwork  cat memudar deteriorated paintwork  engsel/handle/induk kunci/espanyolet iron mongeries Jendela / Windows

 Kusen/ daun jendela hilang, Missing frames and/ or sashes  kaca hilang, missing glass  kaca dicat, painted shut  pengait daun jendela dll, sash cords  daun jendela macet, pulleys, jammed sashes  kaca pecah, broken glass  dempul pecah/ hilang, defective or missing putty  kusen dan dinding renggang, open/loose joints between wall & timber frame

 kayu lapuk, Weather cracking in timberwork  cat memudar deteriorated paintwork  engsel/handle/induk kunci/espanyolet iron mongeries

Parapet/ Parapets

 Bunyi jika diketuk? Structurally sound?,

 Apakah ada flashing yang memadai? appropriate weather flashing?

Deretan Kolom/tiang / Colonnades

 Saluran air apakah mencukupi? Adequate drainage?  Retak di bagian lengkungan, kolom bergerak/ tidak tegak, Cracked archways, movement of columns, lost details

 detil ornament hilang erosi metal, metal grilles erosions Pelapis dinding/ Cladding

 Kondisi pemasangan? Condition of fixings? Prepared by PDA (28/07/17) 13

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA Sheet metal, fiber cement / asbestos cement, cement sheeting, timber boards, ceramics Tangga, balkon, balustrade / Stair, balcony, balusters

 Bed correctly?, Cracks at the neck? Missing sections,

Jeruji, jalusi dan birai / grills, bars & railings Security grilles, decorative elements bricks, concrete, wood, metal: iron, steel, copper, bronze, etc.

Tata tanda / Signage

 Penanda asli, Original  ditambahkan kemudian? added later  Efek visual & psikologis, kondisi sekarang physical and visual impact, condition

3. ELEMEN DALAM DAN RUANG / INTERNAL ELEMENTS & SPACES Item Lantai / Floors Beton, kayu, ubin Concrete, timber, tiles

Kerusakan / Possible Defects  Retak, Crack  miring, sloping  pecah, cracking  tulangan korosi broken tiles, iron bars corroded

Plafon / langit-langit / Ceiling Anyaman & plester, GRC, eternit, lembaran semen, metal, kayu Lath and plaster, fibrous plaster, plasterboard, Prepared by PDA (28/07/17) 14

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA cement sheet, pressed metal, timber Dinding / Walls Bata, kayu, kaca, partisi Brick, timber, glass, partitions

Sambungan ruang / Joinery Pintu jendela, kusen, architraves, bukaan, perkakas Doors and frames, windows, architraves, trim, cupboards

Finishing dinding / Wall finishes Plamir kapur, cat minyak/ akrilik, coating transparan, plitur, lapis granit, dll Limewash, oil & plastic based paints, clear stains and coatings, veneers, marble, stenciled friezes, etc. Pintu (dalam antar ruang) / Door

 Kusen/ daun pintu hilang, Missing frames and/ or sashes  kaca hilang, missing glass  kaca dicat, painted shut  pengait daun jendela dll, sash cords  daun pintu macet, pulleys, jammed sashes  kaca pecah, broken glass  dempul pecah/ hilang, defective or missing putty  kusen dan dinding renggang, open/loose joints between wall & timber frame

 kayu lapuk, Weather cracking in timberwork  cat memudar deteriorated paintwork  engsel/handle/induk kunci/espanyolet iron mongeries

Prepared by PDA (28/07/17) 15

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA

4. AREA SITE / GROUND AREA Item Saluran air, bak kontrol / Drains

Kerusakan / Possible Defects  Tersumbat, Blocked drains  tidak berfungsi, defective  rusak, broken  tidak memadai, inadequate size  tidak tersambung ke bak kontrol & riol kota not connected to storm water

Tanah permukaan / Ground fall

 Apakah menurun kea rah bangunan/ tidak? Ground falls towards the building causing damp

 JIka menurun menuju bangunan menyebabkan bangunan menjadi lembab built up ground has bridged the damp proof course/ above floor level

Tanah di sekitar / Ground areas

 Banjir setempat / Localized flooding,  Genangan air / water ponding,  Area parkir / rear parking to walls

Jalan masuk setapak / Pavements

Pecah/retak, bergelombang Material baru

Taman / Gardens

 Jarak tanaman dengan bangunan seperti akar, Space between building and adjacent trees, eg roots

 jatunya daun, falling leaves  cabang & ranting, overhanging branches

Dinding penahan, talud / Retaining wall

 Retak, Cracking  miring, leaning  drainase memadai, in adequate water drainage

5. PERALATAN PENDUKUNG / SERVICES Item Mekanikal, Elektrikal, AC, Plumbing (air bersih, air kotor, dll), lift, pemadam kebakaran, penangkal petir, system sekuriti, dll

Kerusakan / Possible Defects  Pemasangan berlebihan, invasive fixings  dominasi kabel secara visual, visual impact of cables  jaringan sudah tidak layak expired  pemipaan dan kabel, dll, ducts and pipes, leaking equipment, compliance code impacts, corrosion staining

Prepared by PDA (28/07/17) 16

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA Mechanical, Electrical, Hydraulics, Data/Com/CCTV

G.

CATATAN DAN REKOMENDASI / COMMENTS AND RECOMMENDATION Catatan tim heritage clinic/ Assessor’s recommendations a. Penilaian Kondisi Bangunan Building’s conditions assessment

b. Penilaian perencanaan Bangunan Building Planning & Heritage Impact Assessment

Prepared by PDA (28/07/17) 17

FORMULIR INVESTIGASI & CEK LIST SURVEY KONDISI BANGUNAN HERITAGE BUILDING INVESTIGATION & CONDITION SURVEY CHECK LIST REVITALISASI BANGUNAN CAGAR BUDAYA KOTATUA JAKARTA c. Rekomendasi Rencana & Program lanjutan Recommendation for further program and plan.

Nama penilai/ Assessor: Tanggal penilaian/ Date Assessment:

(Tanda tangan)

Nama pendaftar/ Applicant: Diterima tanggal/ Date Received :

(Tanda tangan)

Prepared by PDA (28/07/17) 18