Bagi Word Formulir Swakelola

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DAFTAR LAMPIRAN DAFTAR LAMPIRAN

Lampiran

Lampiran 1 1 :: MEMORANDUM of UNDERSTANDING (MoU) (TEMPLATE SWAKELOLA - 1)MEMORANDUM of UNDERSTANDING (MoU) (TEMPLATE SWAKELOLA - 1) Lampiran

Lampiran 2 2 :: SURAT PERANIASURAT PERANIAN N SWAKELOSWAKELOLA (TEMPLATE SWAKELOLA - LA (TEMPLATE SWAKELOLA - 2)2) Lampiran

Lampiran ! ! :: SURAT PENUGASAN"PEM#ENTUKAN TIM (TEMPLATE SWAKELOLA - !)SURAT PENUGASAN"PEM#ENTUKAN TIM (TEMPLATE SWAKELOLA - !) Lampiran

Lampiran $a $a :: KERANGKA A%UAN KERA"PROPOSAL TEKNIS PEKERAAN &ISIKKERANGKA A%UAN KERA"PROPOSAL TEKNIS PEKERAAN &ISIK (#ANGUNAN) (TEMPLATE SWAKELOLA - $a)

(#ANGUNAN) (TEMPLATE SWAKELOLA - $a) Lampiran

Lampiran $' $' :: KERANGKA A%UAN KERA PEKERAAN LAINNA (TEMPLATKERANGKA A%UAN KERA PEKERAAN LAINNA (TEMPLATE SWAKELOLA -E SWAKELOLA -$')

$')

Lampiran

Lampiran   :: GAM#AR GAM#AR REN%ANA REN%ANA DAN DAN SPESI&IKASI SPESI&IKASI TEKNIS TEKNIS PEKERAAN PEKERAAN (&ORM (&ORM SW SW - -)

) Lampiran

Lampiran * * :: ADUAL PELAKSANAAN PEKERAAN"KEGIATAN (TEMPLATE SWAKELOLA - *)ADUAL PELAKSANAAN PEKERAAN"KEGIATAN (TEMPLATE SWAKELOLA - *) Lampiran

Lampiran + + :: ADUAL PENGADAAN"KE#UTU,AN #A,AN TENAGA KERA DAN PERALATANADUAL PENGADAAN"KE#UTU,AN #A,AN TENAGA KERA DAN PERALATAN (TEMPLATE SWAKELOLA - +)

(TEMPLATE SWAKELOLA - +) Lampiran

Lampiran . . :: REN%ANA ANGGARAN #IAA (RA#) (TEMPLATE SWAKELOLA - .)REN%ANA ANGGARAN #IAA (RA#) (TEMPLATE SWAKELOLA - .) Lampiran

Lampiran / / :: SK PENGANGKATAN PANITIA PENGADAAN (TEMPLATE SWAKELOLA - /)SK PENGANGKATAN PANITIA PENGADAAN (TEMPLATE SWAKELOLA - /) Lampiran 10a :

Lampiran 10a : LAPORAN ,ASIL SUREI DAN PENGUKURAN &ISIK LAPORAN ,ASIL SUREI DAN PENGUKURAN &ISIK (TEMPLATE SWAKELOLA(TEMPLATE SWAKELOLA - 10a)

- 10a)

Lampiran 10' :

Lampiran 10' : LAPORAN ,ASIL SUREI DAN KONDISI LAPORAN ,ASIL SUREI DAN KONDISI PEKERAAN LAINNA (TEMPLATEPEKERAAN LAINNA (TEMPLATE SWAKELOLA - 10')

SWAKELOLA - 10') L

Laammppiirraan n 1111 :: SURAT PENGAUAN KE#UTU,AN #A,AN"MATERIAL TENAGA KERA SURAT PENGAUAN KE#UTU,AN #A,AN"MATERIAL TENAGA KERA DANDAN PERALATAN (&ORM SM - 11)

PERALATAN (&ORM SM - 11) La

Lampmpiriran 1an 12a2a :: KONTRAK"PERANIAN KONTRAK"PERANIAN PENGADAAN PENGADAAN #ARANG"#A,AN #ARANG"#A,AN (&ORM (&ORM SW SW - -12a)

12a) La

Lampmpiriran 12an 12'' :: KONTRAK"PERANIAN TENAGA A,LI ORANG PERSEORANGAN (&ORMKONTRAK"PERANIAN TENAGA A,LI ORANG PERSEORANGAN (&ORM SW - 12')

SW - 12') La

Lampmpiriran an 1212 :: KONTRAK KERA ORANG PERSEORANGAN #ORONGAN (TEMPLATE SWAKELOLA -KONTRAK KERA ORANG PERSEORANGAN #ORONGAN (TEMPLATE SWAKELOLA -1

122  )) L

Laammppiirraan n 11!! :: LAPORAN PENERIMAAN DAN PENGGUNAAN #A,AN"MATERIAL TENAGALAPORAN PENERIMAAN DAN PENGGUNAAN #A,AN"MATERIAL TENAGA KERA D

KERA DAN AN PERALATAN (&ORM PERALATAN (&ORM SM - SM - 1!)1!) Lampiran 1$a :

Lampiran 1$a : LAPORAN ,ARIAN (TEMPLATE SWAKELOLA - 1$a)LAPORAN ,ARIAN (TEMPLATE SWAKELOLA - 1$a) Lampiran 1$' :

(2)

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Lampiran 1$ :

Lampiran 1$ : LAPORAN #ULANAN (TEMPLATE SWAKELOLA - 1$)LAPORAN #ULANAN (TEMPLATE SWAKELOLA - 1$) Lampiran

Lampiran 1 1 :: SURAT PERMINTAAN USURAT PERMINTAAN UNTUK PEM#ANTUK PEM#AARAARAN (TEMPLATE SWAKELOLA N (TEMPLATE SWAKELOLA - 1)- 1) Lampiran

Lampiran 1* 1* :: DA&TAR ,ADIR (TEMPLATE SWAKELOLA - 1*)DA&TAR ,ADIR (TEMPLATE SWAKELOLA - 1*) Lampiran

Lampiran 1+ 1+ :: PEM#AARAN #A,AN"MATERIAL DAN PERALATAN (TEMPLATE SWAKELOLA -PEM#AARAN #A,AN"MATERIAL DAN PERALATAN (TEMPLATE SWAKELOLA -1+)

1+)

Lampiran

Lampiran 1. 1. :: PANAR KERA (TEMPLATE SWAKELOLA - 1.)PANAR KERA (TEMPLATE SWAKELOLA - 1.) Lampiran 1/a :

Lampiran 1/a : REALISASI PEKERAAN &ISIK (TEMPLATE SWAKELOLA - 1/a)REALISASI PEKERAAN &ISIK (TEMPLATE SWAKELOLA - 1/a) Lampiran 1/' :

Lampiran 1/' : REALISAREALISASI PEKERAAN LAINNA (TEMPLATE SWAKELOLA - SI PEKERAAN LAINNA (TEMPLATE SWAKELOLA - 1/a)1/a) Lampiran

Lampiran 20 20 :: LAPORAN LAPORAN PEKERAAN SELESPEKERAAN SELESAI (TEMPLATE SWAKELAI (TEMPLATE SWAKELOLA - OLA - 20)20) Lampiran Laporan P343r5aan S3637ai (Lampiran 1)

Lampiran Laporan P343r5aan S3637ai (Lampiran 1) Lampiran Laporan P343r5aan S3637ai (Lampiran 2) Lampiran Laporan P343r5aan S3637ai (Lampiran 2) Lampiran

Lampiran 21 21 :: #ERITA A%ARA PENERA,AN PEKERAAN SELESAI (TEMPLATE SWAKELOLA -#ERITA A%ARA PENERA,AN PEKERAAN SELESAI (TEMPLATE SWAKELOLA -21)

21)

Lampiran

Lampiran 22 22 :: LEM#AR PENGAWASAN"DA&TAR SIMAK (TEMPLATE SWAKELOLA - 22)LEM#AR PENGAWASAN"DA&TAR SIMAK (TEMPLATE SWAKELOLA - 22) Lampiran

Lampiran 2! 2! :: SURAT SURAT PENUGASAN PENUGASAN UNTUK PEUNTUK PEMERIKSAAN MERIKSAAN DAN DAN EALUASI EALUASI (&ORM (&ORM SW -SW -2!)

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Lampiran 1 : MEMORANDUM of UNDERSTANDING (MoU) (TEMPLATE

SWAKELOLA - 1)

KOP SURAT KOP SURAT

NASKA, KESEPAKATAN KERASAMA NASKA, KESEPAKATAN KERASAMA

an8ara an8ara 999999999999999999 999999999999999999 ;3n<an ;3n<an 999999999999999999 999999999999999999 NOMOR : NOMOR : Pa;

Pa;a =ari inia =ari ini 99999999 8an< 8an<<a6<a6 99999999 '>6'>6anan 999999 8a= 8a=>n>n 99999999 '3r83m '3r83mpa8 ;ipa8 ;i 9999 4ami ?an< '3r8an;a 8an<an ;i 'a@a= ini :

4ami ?an< '3r8an;a 8an<an ;i 'a@a= ini :       (736an5>8n?a ;i73'>8 73'a<ai PI,AK PERTAMA) (736an5>8n?a ;i73'>8 73'a<ai PI,AK PERTAMA)

Dan Dan       (736an5>8n?a ;i73'>8 73'a<ai PI,AK KEDUA) (736an5>8n?a ;i73'>8 73'a<ai PI,AK KEDUA)

PI,AK PERTAMA ;an PI,AK KEDUA 73ara '3r7ama-7ama m3n?a8a4an 73pa4a8 ;an 738>5> PI,AK PERTAMA ;an PI,AK KEDUA 73ara '3r7ama-7ama m3n?a8a4an 73pa4a8 ;an 738>5> >n8>4 m3m'>a8 Na74a=

>n8>4 m3m'>a8 Na74a= K373pa4a8an K3r5a7ama ;3n<an 4383n8>an 73'a<ai '3ri4>8 :K373pa4a8an K3r5a7ama ;3n<an 4383n8>an 73'a<ai '3ri4>8 :

TUUAN KERASAMA TUUAN KERASAMA

Pa7a6 1 Pa7a6 1

Na74a= K373pa4a8an K3r5a7ama '3r8>5>an >n8>4 m3nin<4a84an 4>a6i8a7 p36a47anaan 8><a7 Na74a= K373pa4a8an K3r5a7ama '3r8>5>an >n8>4 m3nin<4a84an 4>a6i8a7 p36a47anaan 8><a7 ;

;aan n ff>>nn<<77i i mmaa77iinn<<--mmaa77iinn< < ppii==aa4 4 773377>>aai i 4433@@33nnaann<<aan n ??aann< < aa;;aa pa;a

pa;a   ;an ;an   73'a<ai 73'a<ai 63m'a<a63m'a<a p3n;i;i4an 8in<<i

p3n;i;i4an 8in<<i

RUANG LINGKUP KERASAMA RUANG LINGKUP KERASAMA

Pa7a6 2 Pa7a6 2 Na74a

Na74a= = K373K373pa4apa4a8an 8an K3r5aK3r5a7ama 73'a<ai7ama 73'a<aimana ;ima47>;4mana ;ima47>;4an an ;a6a;a6am m pa7a6 1 pa7a6 1 (7a8>) ;i (7a8>) ;i a8a7a8a7 m

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9999999999999999999999999999999999999  

PELAKSANAAN KEGIATAN Pa7a6 !

K373pa4a8an K3r5a7ama ini a4an ;i8in;a46an5>8i ;an ;ia8>r ;a6am 7>ra8 p3r5an5ian 83r73n;iri ?an< ;i'>a8 o63= PI,AK PERTAMA ;an PI,AK KEDUA a8a> o63= p35a'a8 ?an< ;i8>n5>4 ;an ;i'3ri @3@3nan< o63= 43;>a '36a= pi=a4 >n8>4 m36a47ana4an =a6 83r73'>8

PEM#IAAAN Pa7a6 $

P3m'ia?aan ?an< 8im'>6 73'a<ai a4i'a8 ;ari 43<ia8an Na74a= K373pa4a8an K3r5a7ama ini a4an ;ia8>r ;an ;i8>an<4an ;a6am P3r5an5ian P36a47anaan K3r5a7ama ?an< a4an ;i7>7>n 63'i= 6an5>8 ;an ;i8an;a8an<ani o63= p35a'a8 ?an< ;i8>n5>4 " ;i8><a74an o63= ma7in<-ma7in< pi=a4

ANGKA WAKTU Pa7a6 

Na74a= K373pa4a8an K3r5a7ama ini '3r6a4> >n8>4 5an<4a @a48> 83r=i8>n< 735a4 ;i8an;a8an<ani 7ampai ;3n<an  ;an ;apa8 ;ip3rpan5an< ;i>'a= ma>p>n ;ia4=iri a8a7 p3r738>5>an 43;>a '36a= pi=a4

PENUTUP Pa7a6 *

1 Na74a= K373pa4a8an K3r5a7ama ini ;i'>a8 ;a6am ran<4ap 2 (;>a) a76i ma7in<-ma7in< '3rma83rai >4>p 73r8a m3mp>n?ai 434>a8an =>4>m ?an< 7ama 73836a= ;i8an;a8an<ani o63= 43;>a '36a= pi=a4 ;an ;i'>'>=i ap 63m'a<a ma7in<-ma7in<

2 ,a6-=a6 ?an< '36>m ;ia8>r ;a6am Na74a= K373pa4a8an K3r5a7ama ini a4an ;ia8>r 43m>;ian a8a7 p3r738>5>an 43;>a '36a= pi=a4

! Na74a= K373pa4a8an K3r5a7ama ini m>6ai '3r6a4> 735a4 ;i8an;a8an<ani ;3n<an 4383n8>an 'a=@a 73<a6a 737>a8>n?a a4an ;ip3r'ai4i 73'a<aimana m378in?a apa'i6a ;i43m>;ian =ari 83r;apa8 43436ir>an

PI,AK KEDUA PI,AK PERTAMA

999999999999999 999999999999999

 

(6)

Lampiran  : SURAT PER!AN!IAN SWAKELOLA (TEMPLATE SWAKELOLA - ) KOP SURAT SURAT PER!AN!IAN SWAKELOLA ANTARA K"L"D"I ########################################################## D$n%an ILPS ########################################################## Nomor : &&&&&&&&&&&&&&&& Tan%%a' : &&&&&&&&&&&&&&&& T3n8an< &&&&&&&&&&&&&&&&&&&&&&&#

SURAT PERANIAN ini '3ri4>8 73m>a 6ampirann?a (736an5>8n?a ;i73'>8 Kon8ra4B) ;i'>a8 ;an ;i8an;a8an<ani ;i  pa;a =ari  8an<<a6  '>6an  8a=>n  an8ara   736a4> P35a'a8 P3m'>a8 Komi8m3n ?an< '3r8in;a4 >n8>4 ;an a8a7 nama K"L"D"I   ?an< '3r43;>;>4an ;i  No# #### T$'p# (########################) ################  '3r;a7ar4an S>ra8 K3p>8>7an 9999999999 No 999999999 (736an5>8n?a ;i73'>8  Pia) I B) ;an #######################  D$an Fa*'+a, #################################################### 

?an< '3r8in;a4 >n8>4 ;an a8a7 nama

Fa*'+a, ###################################################################  ?an< '3r43;>;>4an ;i ######################################################  ( Pia) II B)

MENGINGAT #A,WA:

(a) Pia I 836a= m3min8a Pia II >n8>4 m36a47ana4an 43<ia8an

############################################### 73'a<aimana ;i83ran<4an ;a6am K$ran%a A*an K$r.a (KAK) ?an< 83r6ampir ;a6am Kon8ra4 ini (736an5>8n?a ;i73'>8 P$$r.aan S/a$'o'aB)C

(7)

(') Pia II 73'a<aimana ;in?a8a4an 43pa;a Pia I m3mi6i4i 43a=6ian prof37iona6 p3r7oni6 ;an 7>m'3r ;a?a 834ni7 73r8a 836a= m3n?38>5>i >n8>4 m36a47ana4an p$$r.aan ,/a$'o'a 737>ai ;3n<an p3r7?ara8an ;an 4383n8>an ;a6am Kon+ra) iniC () Pia I ;an Pia II m3n?a8a4an m3mi6i4i 43@3nan<an >n8>4 m3nan;a8an<ani

Kon8ra4 ini ;an m3n<i4a8 pi=a4 ?an< ;i@a4i6iC

(;) Pia I ;an Pia II m3n<a4>i ;an m3n?a8a4an 'a=@a 73=>'>n<an ;3n<an p3nan;a8an<anan Kon8ra4 ini ma7in<-ma7in< pi=a4:

1) 836a= ;an 73nan8ia7a ;i'3ri4an 4373mpa8an >n8>4 ;i;ampin8C

!) 836a= m3m'aa ;an m3ma=ami 73ara p3n>= 4383n8>an Kon8ra4 iniC

$) 836a= m3n;apa84an 4373mpa8an ?an< m3ma;ai >n8>4 m3m3ri47a ;an m3n<4onfirma7i4an 73m>a 4383n8>an ;a6am Kon8ra4 ini '373r8a 73m>a fa48a ;an ;an 4on;i7i ?an< 83r4ai8

MAKA OLE, KARENA ITU Pia I ;an Pia II ;3n<an ini '3r73pa4a8 ;an m3n?38>5>i =a6-=a6 73'a<ai '3ri4>8:

1 P343r5aan ?an< ;ima47>; ;a6am 4on8ra4 ini a;a6a= P36a47anaan 99999999999999999999999999999999999999999999999 2 To8a6 Ni6ai Kon8ra4 a;a6a= 73'37ar Rp 

()C

! p3ri78i6a=an ;an >n<4apan ;a6am S>ra8 P3r5an5ian ini m3mi6i4i ar8i ;an ma4na ?an< 7ama 73p3r8i ?an< 83ran8>m ;a6am 6ampiran S>ra8 P3r5an5ian iniC

$ ;o4>m3n-;o4>m3n '3ri4>8 (736an5>8n?a ;i73'>8 Do*m$n Kon+ra B) m3r>pa4an 7a8>-437a8>an ;an 'a<ian ?an< 8i;a4 83rpi7a=4an ;ari Kon8ra4 ini :

a

P3r5an5ianC

'

K3ran<4a A>an K3r5a (KAK)



Daf8ar 4>an8i8a7 ;an =ar<a (apa'i6a a;a)C

;

a;@a6 P36a47anaan

3

Do4>m3n 6ainn?a 73p3r8i: 5aminan-5aminan SPP# #A,P (apa'i6a a;a)

 Do4>m3n Kon8ra4 ;i'>a8 >n8>4 7a6in< m3n536a74an 7a8> 7ama 6ain ;an 5i4a 83r5a;i p3r83n8an<an an8ara 4383n8>an ;a6am 7>a8> ;o4>m3n ;3n<an 4383n8>an ;a6am ;o4>m3n ?an< 6ain ma4a ?an< '3r6a4> a;a6a= 4383n8>an ;a6am ;o4>m3n ?an< 63'i= 8in<r>8an =i3rar4i pa;a an<4a ! ;i a8a7C

 ,a4 ;an 43@a5i'an 8im'a6-'a6i4 PI,AK I ;an Pi=a4 II ;in?a8a4an ;a6am Kon8ra4 ?an< m36ip>8i 4=>7>7n?a :

a. _{PI,AK I m3mp>n?ai =a4 ;an 43@a5i'an >n8>4 :}

1) m3n<a@a7i ;an m3m3ri47a p343r5aan ?an< ;i6a47ana4an o63= Pi=a4 IIC

2) m3min8a 6aporan-6aporan 73ara p3rio;i4 m3n<3nai p36a47anaan p343r5aan ?an< ;i6a4>4an o63= Pi=a4 IIC

(8)

!) m3m'a?ar p343r5aan 737>ai ;3n<an =ar<a ?an< 83ran8>m ;a6am Kon8ra4 ?an< 836a= ;i838ap4an 43pa;a Pi=a4 IIC

b. _{Pi=a4 II m3mp>n?ai =a4 ;an 43@a5i'an >n8>4 :}

1) m3n3rima p3m'a?aran >n8>4 p36a47anaan p343r5aan 737>ai ;3n<an =ar<a ?an< 836a= ;i83n8>4an ;a6am Kon8ra4C

2) m36apor4an p36a47anaan p343r5aan 73ara p3rio;i4 43pa;a PI,AK IC

!) m36a47ana4an ;an m3n?3637ai4an p343r5aan 737>ai ;3n<an 5a;@a6 p36a47anaan p343r5aan ?an< 836a= ;i838ap4an ;a6am Kon8ra4C

$) m36a47ana4an ;an m3n?3637ai4an p343r5aan 73ara 3rma8 a4>ra8 ;an p3n>= 8an<<>n< 5a@a' ;3n<an m3n?3;ia4an 83na<a 43r5a 'a=an-'a=an p3ra6a8an an<4>8an 43 a8a> ;ari 6apan<an ;an 73<a6a p343r5aan p3rman3n ma>p>n 73m3n8ara ?an< ;ip3r6>4an >n8>4 p36a47anaan p3n?3637aian ;an p3r'ai4an p343r5aan ?an< ;irini ;a6am Kon8ra4C

) m3m'3ri4an 4383ran<an-4383ran<an ?an< ;ip3r6>4an >n8>4 p3m3ri47aan p36a47anaan ?an< ;i6a4>4an PI,AK IC

*) m3n?3ra=4an =a7i6 p343r5aan 737>ai ;3n<an 5a;@a6 p3n?3ra=an p343r5aan ?an< 836a= ;i838ap4an ;a6am Kon8ra4C

* Kon8ra4 ini m>6ai '3r6a4> 3f348if 83r=i8>n< 735a4 8an<<a6 ?an< ;i838ap4an ;a6am Do4>m3n Kon8ra4 ;3n<an 8an<<a6 m>6ai ;an p3n?3637aian 43736>r>=an p343r5aan 73'a<aimana ;ia8>r ;a6am Do4>m3n Kon8ra4

DENGAN DEMIKIAN PI,AK I ;an Pi=a4 II 836a= '3r73pa4a8 >n8>4 m3nan;a8an<ani Kon8ra4 ini pa;a 8an<<a6 83r73'>8 ;i a8a7 ;an m36a47ana4an Kon8ra4 737>ai ;3n<an 4383n8>an p3ra8>ran p3r>n;an<->n;an<an ;i R3p>'6i4 In;on37ia

Un8>4 ;an a8a7 nama PI,AK I

########################################## NIP# #########################################

Un8>4 ;an a8a7 nama Pi=a4 II

########################################## NIP# #########################################

(9)

Lampiran 0 : SURAT PENUGASAN"PEMENTUKAN TIM (TEMPLATE SWAKELOLA -0)

KOP SURAT

KEPUTUSAN PE!AAT PEMUAT KOMITMEN KEGIATAN ################################################################## SATUAN KER!A ###################################################################### ####################################################################################################### K"L"D"I #################################### NOMOR : ################################### TENTANG

PEMENTUKAN TIM KEGIATAN SWAKELOLA

KEGIATAN ############################################################################## #############################################################################################

K"L"D"I ################################### TA2UN ANGGARAN ########

M$nim3an% : a #a=@a >n8>4 m3n<a;a4an

p343r5aan 9999999?an< ;i6a47ana4an 73ara S@a436o6a p3r6> ;i'3n8>4 Tim S@a436o6a

' #a=@a para P35a'a8"P38><a7

;i'a@a= ini ;ipan;an< mamp> ;an m3m3n>=i 7?ara8 >n8>4 m36a47ana4an 8><a7 73'a<ai Tim S@a436o6a

 #a=@a >n8>4 ma47>; 83r73'>8 ma4a p3r6> ;i436>ar4an S>ra8 P3m'3n8>4an"P3n><a7anC

M$n%in%a+ : 1 P3ra8>ran Pr37i;3n R3p>'6i4 In;on37ia No $ Ta=>n 2010 T3n8an< P3n<a;aan #aran<"a7a P3m3rin8a=C

2 K3p>8>7an 9C ! 9999999999999999999999999999 999999C $ 99999999999999999999999999999 999;78 MEMUTUSKAN M$n$+apan :

K$,a+* : M3m'3n8>4 Tim 7@a436o6a ?an< 83r;iri ;ari Tim P3r3nana Tim P36a47ana ;an Tim P3n<a@a7 K3<ia8an S@a436o6a ;i9999 P343r5aan99999999999999 ;3n<an 7>7>nan 73'a<ai '3ri4>8 :

(10)

Tim P3r3nana : 1 S;r 9999999999999999999999973'a<ai K38>a TimC 2 S;r 9999999999999999999973'a<ai S34r38ari7 TimC ! S;r 99999999999999999999973'a<ai An<<o8a TimC $ 999999999999999999999999 999999999;78 Tim P36a47ana :

(Un8>4 S@a436o6a Tip3 2: In78an7i P3m3rin8a= Lain Tim P36a47ana ;i838ap4an o63= In78an7i P36a47ana S@a436o6a)

1 S;r 9999999999999999999999973'a<ai K38>a TimC 2 S;r 9999999999999999999973'a<ai S34r38ari7 TimC ! S;r 99999999999999999999973'a<ai An<<o8a TimC $ 999999999999999999999999 999999999;78 Tim P3n<a@a7 : 1 S;r 9999999999999999999999973'a<ai K38>a TimC 2 S;r 9999999999999999999973'a<ai S34r38ari7 TimC ! S;r 99999999999999999999973'a<ai An<<o8a TimC $ 999999999999999999999999 999999999;78

K$4*a : Tim P3r3nana K3<ia8an S@a436o6a m3mp>n?ai 8><a7 ;an 8an<<>n< 5a@a' 73'a<ai '3ri4>8 :

1 ########################( K38>a Tim) a  C '  C 2 #########################( S34r38ari7 Tim) a  C '  C ! #########################( An<<o8a Tim) a 

(11)

C

'  ;78C

Tim P36a47ana K3<ia8an S@a436o6a m3mp>n?ai 8><a7 ;an 8an<<>n< 5a@a' 73'a<ai '3ri4>8 :

(Un8>4 S@a436o6a Tip3 2: In78an7i P3m3rin8a= Lain Tim P36a47ana ;i838ap4an o63= In78an7i P36a47ana S@a436o6a)

1 ########################( K38>a Tim) a  C '  C 2 #########################( S34r38ari7 Tim) a  C '  C ! #########################( An<<o8a Tim) a  C '  ;78C

Tim P3n<a@a7 K3<ia8an S@a436o6a m3mp>n?ai 8><a7 ;an 8an<<>n< 5a@a' 73'a<ai '3ri4>8 :

1 ########################( K38>a Tim) a  C '  C 2 #########################( S34r38ari7 Tim) a  C '  C ! #########################( An<<o8a Tim) a  C '  ;78C

K$+i%a : K3pa;a 8im p3r3nana 8im p36a47ana ;an 8im p3n<a@a7 ;i'3ri4an =onorari>m 737>ai 43;>;>4ann?a ;a6am 8im ;an '3r;a7ar4an p3n><a7an ?an< '3r7an<4>8an 73'a<aimana ;i838ap4an m36a6>i S>ra8

(12)

P3rin8a= T><a7 (SPT) ;3n<an 4383n8>an p3ra8>ran p3r>n;an<->n;an<an ?an< '3r6a4>C

K$$mpa+ : Apa'i6a ;ipan;an< p3r6> 8im p3r3nana 8im p36a47ana ;an 8im p3n<a@a7 ;apa8 m3r34r>8 83na<a nara7>m'3r"in78r>48>r"83na<a a=6i ;ari in78an7i a8a> 436ompo4 ma7?ara4a8 ?an< ;ian<<ap m3mi6i4i 4omp383n7i ;i 'i;an<n?a 737>ai 43<ia8an 7@a436o6a ?an< a4an ;i7363n<<ara4an

K$'ima : Ma7a 8><a7 8im p3r3nana 8im p36a47ana ;an 8im p3n<a@a7 43<ia8an 7@a436o6a 736ama  () '>6an ;an a8a> ;in?a8a4an '3ra4=ir 73836a= p36a47anaan 43<ia8an 7@a436o6a ;ima47>; 73637ai ;3n<an 83r63'i= ;a=>6> m3n?ampai4an 6aporan a4=irC

K$$nam : S3<a6a 'ia?a 73'a<ai a4i'a8 ;i6a47ana4ann?a 43p>8>7an ini ;i'3'an4an pa;a An<<aran K3<ia8an  Sa8>an K3r5a  K"L"D"I Ta=>n An<<aran 

K$+*.* : K3p>8>7an ini '3r6a4> 735a4 8an<<a6 ;i838ap4an ;3n<an 4383n8>an 'a=@a apa'i6a ;i43m>;ian =ari 83r;apa8 43436ir>an ;a6am p3n38apan ini a4an ;ia;a4an p3r'ai4an

D3mi4ian a<ar p3n><a7an ini ;i6a47ana4an ;3n<an 73'ai4-'ai4n?a ;an ;3n<an p3n>= 8an<<>n< 5a@a'

DITETAPKAN DI: 99999999999 PADA TANGGAL: 99999999999

P35a'a8 P3m'>a8 Komi8m3n

999 999999999999 NIP 9999999999 TEM#USAN S>ra8 P3n><a7an ini ;i7ampai4an 43pa;a 8= :

1 999999999999999999999

2 9999999999999999999;78

Lampiran 5a : KERANGKA A6UAN KER!A PEKER!AAN FISIK (ANGUNAN) (TEMPLATE SWAKELOLA - 5a)

KERANGKA A6UAN KER!A

Pa$+ P$$r.aan99999999999999  ( nama pa438 p343r5aan ) )

(13)

Ta=>n An<<aran 200

%a8a8an :

(14)

A. _{KERANGKA A6UAN KER!A (KAK)}

1. _{LATAR ELAKANG} _{} 9999999999999999999999999)

2. _{MAKSUD DAN TU!UAN} _Ma47>;

9999999999999999999999999) T>5>an 999999999999999999999999 ) 3. _SASARAN _{1 } ) 2  ) !  ) $ ;78) 4. _{NAMA DAN} ORGANISASI PE!AAT PEMUAT KOMITMEN  

(;ii7i o63= 8im p3r3nana on8o= : P35a'a8 P3m'>a8 Komi8m3n K3<ia8an P3n?>7>nan P3n?3mp>rnaan"P3n<54a5ian P3ra8>ran P3r>n;an<-Un;an<an Sa8>an K3r5a #a;an P3n<3m'an<an S>m'3r Da?a Man>7ia)

5. _{SUMER PENDANAAN} _{Un8>4 p36a47anaan 43<ia8an ini ;ip3r6>4an 'ia?a 4>ran< 63'i=} Rp 99999 ( 999999 ) 83rma7>4 PPN

;i'ia?ai AP#N Ta=>n An<<aran 200 )

6. _{LINGKUP7 LOKASI}

KEGIATAN7 DATA DAN FASILITAS PENUN!ANG SERTA ALI2

PENGETA2UAN

a Lin<4>p K3<ia8an

Lin<4>p 43<ia8an ini a;a6a= :

1) )

2) )

!) ;78)

' Lo4a7i K3<ia8an

K3<ia8an 7@a436o6a ini =ar>7 ;i6a47ana4an ;i @i6a?a= N3<ara K37a8>an R3p>'6i4 In;on37ia

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 Da8a ;an &a7i6i8a7 P3n>n5an< (5i4a ;ip3r6>4an) 1) P3n?3;iaan o63= P35a'a8 P3m'>a8 Komi8m3n

Da8a ;an fa7i6i8a7 ?an< ;i73;ia4an o63= P35a'a8 P3m'>a8 Komi8m3n ?an< ;apa8 ;i<>na4an ;an =ar>7 ;ip36i=ara o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73oran<an ('i6a a;a):

a) Laporan ;an Da8a

K>mp>6an 6aporan ;an ;a8a 73'a<ai =a7i6 78>;i 83r;a=>6> 73r8a p=o8o<rafi ('i6a a;a)

(n?a8a4an 'i6a a;a 6aporan ;an ;a8a"informa7i ?an< ;apa8 ;ipa4ai 73'a<ai r3f3r3n7i o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73oran<an ('i6a a;a)) ') A4omo;a7i ;an R>an<an Kan8or

(36a74an ;an n?a8a4an apa4a= a;a a4omo;a7i ;an r>an<an 4an8or ?an< a4an ;i73;ia4an o63= P35a'a8 P3m'>a8 Komi8m3n mi7a6n?a r>an<an 4an8or 6>a7">4>rann?a ;an 43a;aann?a a8a> =ar>7 ;i73;ia4an o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73oran<an ('i6a a;a) ;3n<an

ara 73@a)

) S8af P3n<a@a7"P3n;ampin<

(P35a'a8 P3m'>a8 Komi8m3n ;apa8 m3n<an<4a8 p38><a7 a8a> @a4i6n?a ?an< '3r8in;a4 73'a<ai p3n<a@a7 a8a> p3n;ampin< (o>n83rpar8) a8a> pro538 offi3r (PO) ;a6am ran<4a p36a47anaan 7@a436o6a)

;)&a7i6i8a7 ?an< ;i73;ia4an o63= P35a'a8 P3m'>a8 Komi8m3n ?an< ;apa8 ;i<>na4an o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73oran<an ('i6a a;a) (%an8>m4an nama ;an 5>m6a= 'aran< 83r73'>8)) 2) P3n?3;iaan o63= 8im 7@a436o6a a8a> p3n?3;ia

5a7a"p3n?3;ia 5a7a p3r73oran<an

Tim 7@a436o6a a8a> p3n?3;ia 5a7a " p3n?3;ia 5a7a p3r73oran<an =ar>7 m3n?3;ia4an ;an m3m36i=ara 73m>a fa7i6i8a7 ;an p3ra6a8an ?an< ;ip3r<>na4an >n8>4 436anaran p36a47anaan p343r5aan

(%an8>m4an nama ;an 5>m6a= 'aran<-'aran< ?an< =ar>7 ;i73;ia4an o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a " p3n?3;ia 5a7a p3r73oran<an ;an 838ap4an 5><a apa4a= =ar>7 ;i'36i a8a7 nama P35a'a8 P3m'>a8 Komi8m3n a8a> =ar>7 ;3n<an ara 73@a)

; A6i= P3n<38a=>an

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ma4a 8im 7@a436o6a a8a> p3n?3;ia 5a7a " p3n?3;ia 5a7a p3r73oran<an =ar>7 m3n<a;a4an p36a8i=an 4>r7>7 7in<4a8 ;i74>7i ;an 73minar 83r4ai8 ;3n<an 7>'78an7i p36a47anaan p343r5aan ;a6am ran<4a a6i= p3n<38a=>an 43pa;a 78af ;i 6in<4>n<an or<ani7a7i P35a'a8 P3m'>a8 Komi8m3n

7. _{PENDEKATAN DAN} METODOLOGI " METODE PELAKSANAAN " SPESIFIKASI TEKNIS a ) ' ) ;78) 8. _{!ANGKA WAKTU} PELAKSANAAN

an<4a @a48> p36a47anaan 43<ia8an ini ;ip3r4ira4an 9 (9 )) '>6an

9. _{TENAGA A2LI} _{P3n?3;ia 5a7a =ar>7 '3r8in;a4 73'a<ai T3na<a A=6i ?an<} ;ip3r6>4an >n8>4 m36a47ana4an p343r5aan ini a;a6a= T3na<a A=6i ) T3na<a A=6i ?an< ;i7?ara84an a;a6a= Sar5ana ) S8ra8a 9) (S) 6>6>7an >ni3r7i8a7"p3r<>r>ran 8in< ?an< ;i7ama4an ?an< '3rp3n<a6aman m36a47ana4an p343r5aan ;i'i;an< 99) 7>''i;an<) S34>ran<-4>ran<n?a  (9) 8a=>n)

10. KELUARAN K36>aran ?an< ;i=a7i64an ;ari p36a47anaan p343r5aan ini a;a6a= ) 11. _LAPORAN _{3ni7 6aporan ?an< =ar>7 ;i73ra=4an 43pa;a} _{P35a'a8 P3m'>a8}

Komi8m3n a;a6a=:

a Laporan #>6anan

' Laporan R3a6i7a7i P343r5aan

 Laporan P3n<a@a7an ;an Ea6>a7i ; Laporan K=>7>7 ('i6a ;ip3r6>4an) Laporan '>6anan =ar>7 ;i73ra=4an 738iap a4=ir '>6an 735a4 SPMK ;i83r'i84an 73'an?a4 9 (9999)) '>4> 6aporan ;an %D '3ri7i 736>r>= 6aporan 83rma7>4 7>mmar? r3por8 9 (9) ) '>a=

PEA#AT PEM#UAT KOMITMEN

( 99999999999 ) NIP99999999

(17)

Lampiran 53 : KERANGKA A6UAN KER!A PEKER!AAN LAINN8A(TEMPLATE SWAKELOLA - 53)

KERANGKA A6UAN KER!A

Pa$+ P$$r.aan99999999999999  ( nama pa438 p343r5aan ) )

(18)

%a8a8an :

(19)

B. _{KERANGKA A6UAN KER!A (KAK)}

1. _{LATAR ELAKANG} _{}

9999999999999999999999999)

2. _{MAKSUD DAN TU!UAN} _Ma47>;

9999999999999999999999999) T>5>an 999999999999999999999999 ) 3. _SASARAN _{1 )} 2 ) ! ) $ ;78 ) 4. _{NAMA DAN} ORGANISASI PE!AAT PEMUAT KOMITMEN   (;ii7i o63= 8im p3r3nana on8o= : P35a'a8 P3m'>a8 Komi8m3n 9999999999999999999999)

5. _{SUMER PENDANAAN} _{Un8>4 p36a47anaan 43<ia8an ini ;ip3r6>4an 'ia?a 4>ran< 63'i=}

Rp 99999 ( 999999 ) 83rma7>4 PPN ;i'ia?ai AP#N Ta=>n An<<aran 200 )

6. _{LINGKUP7 LOKASI}

KEGIATAN7 DATA DAN FASILITAS PENUN!ANG SERTA ALI2

PENGETA2UAN

a Lin<4>p K3<ia8an

Lin<4>p 43<ia8an ini a;a6a= :

1) ) 2) ) !) ;78) ' Lo4a7i K3<ia8an

K3<ia8an 7@a436o6a ini =ar>7 ;i6a47ana4an ;i @i6a?a= N3<ara K37a8>an R3p>'6i4 In;on37ia

 Da8a ;an &a7i6i8a7 P3n>n5an< (5i4a ;ip3r6>4an) !) P3n?3;iaan o63= P35a'a8 P3m'>a8 Komi8m3n

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Komi8m3n ?an< ;apa8 ;i<>na4an ;an =ar>7 ;ip36i=ara o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73oran<an ('i6a a;a):

a) Laporan ;an Da8a

K>mp>6an 6aporan ;an ;a8a 73'a<ai =a7i6 78>;i 83r;a=>6> 73r8a p=o8o<rafi ('i6a a;a)

(n?a8a4an 'i6a a;a 6aporan ;an ;a8a"informa7i ?an< ;apa8 ;ipa4ai 73'a<ai r3f3r3n7i o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73oran<an ('i6a a;a)) ') A4omo;a7i ;an R>an<an Kan8or

(36a74an ;an n?a8a4an apa4a= a;a a4omo;a7i ;an r>an<an 4an8or ?an< a4an ;i73;ia4an o63= P35a'a8 P3m'>a8 Komi8m3n mi7a6n?a r>an<an 4an8or 6>a7">4>rann?a ;an 43a;aann?a a8a> =ar>7 ;i73;ia4an o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73oran<an ('i6a a;a) ;3n<an

ara 73@a)

) S8af P3n<a@a7"P3n;ampin<

(P35a'a8 P3m'>a8 Komi8m3n ;apa8 m3n<an<4a8 p38><a7 a8a> @a4i6n?a ?an< '3r8in;a4 73'a<ai p3n<a@a7 a8a> p3n;ampin< (o>n83rpar8) a8a> pro538 offi3r (PO) ;a6am ran<4a p36a47anaan 7@a436o6a)

;)&a7i6i8a7 ?an< ;i73;ia4an o63= P35a'a8 P3m'>a8 Komi8m3n ?an< ;apa8 ;i<>na4an o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73oran<an ('i6a a;a) (%an8>m4an nama ;an 5>m6a= 'aran< 83r73'>8)) $) P3n?3;iaan o63= 8im 7@a436o6a a8a> p3n?3;ia

5a7a"p3n?3;ia 5a7a p3r73oran<an

Tim 7@a436o6a a8a> p3n?3;ia 5a7a " p3n?3;ia 5a7a p3r73oran<an =ar>7 m3n?3;ia4an ;an m3m36i=ara 73m>a fa7i6i8a7 ;an p3ra6a8an ?an< ;ip3r<>na4an >n8>4 436anaran p36a47anaan p343r5aan

(%an8>m4an nama ;an 5>m6a= 'aran<-'aran< ?an< =ar>7 ;i73;ia4an o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a " p3n?3;ia 5a7a p3r73oran<an ;an 838ap4an 5><a apa4a= =ar>7 ;i'36i a8a7 nama P35a'a8 P3m'>a8 Komi8m3n a8a> =ar>7 ;3n<an ara 73@a)

; A6i= P3n<38a=>an

Apa'i6a ;ipan;an< p3r6> o63= P35a'a8 P3m'>a8 Komi8m3n  ma4a 8im 7@a436o6a a8a> p3n?3;ia 5a7a " p3n?3;ia 5a7a p3r73oran<an =ar>7 m3n<a;a4an p36a8i=an 4>r7>7 7in<4a8 ;i74>7i ;an 73minar 83r4ai8 ;3n<an 7>'78an7i p36a47anaan p343r5aan ;a6am ran<4a a6i= p3n<38a=>an 43pa;a 78af ;i 6in<4>n<an or<ani7a7i P35a'a8 P3m'>a8 Komi8m3n

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7. _{PENDEKATAN DAN} METODOLOGI a ) ' ) ;78) 8. !ANGKA WAKTU PELAKSANAAN

an<4a @a48> p36a47anaan 43<ia8an ini ;ip3r4ira4an 9 (9 )) '>6an

9. _{TENAGA A2LI} _{P3n?3;ia 5a7a =ar>7 '3r8in;a4 73'a<ai T3na<a A=6i ?an<} ;ip3r6>4an >n8>4 m36a47ana4an p343r5aan ini a;a6a= T3na<a A=6i ) T3na<a A=6i ?an< ;i7?ara84an a;a6a= Sar5ana ) S8ra8a 9) (S) 6>6>7an >ni3r7i8a7"p3r<>r>ran 8in< ?an< ;i7ama4an ?an< '3rp3n<a6aman m36a47ana4an p343r5aan ;i'i;an< 99) 7>''i;an<) S34>ran<-4>ran<n?a  (9) 8a=>n)

10. _KELUARAN _{K36>aran ?an< ;i=a7i64an ;ari p36a47anaan p343r5aan ini a;a6a=} ) 11. _LAPORAN _{3ni7 6aporan ?an< =ar>7 ;i73ra=4an 43pa;a} _{P35a'a8 P3m'>a8}

Komi8m3n a;a6a=:

a Laporan #>6anan

' Laporan R3a6i7a7i P343r5aan

 Laporan P3n<a@a7an ;an Ea6>a7i ; Laporan K=>7>7 ('i6a ;ip3r6>4an) Laporan '>6anan =ar>7 ;i73ra=4an 738iap a4=ir '>6an 735a4 SPMK ;i83r'i84an 73'an?a4 9 (9999)) '>4> 6aporan ;an %D '3ri7i 736>r>= 6aporan 83rma7>4 7>mmar? r3por8 9 (9) ) '>a=

PEA#AT PEM#UAT KOMITMEN

( 99999999999 ) NIP99999999

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Lampiran 9 : GAMAR REN6ANA DAN SPESIFIKASI TEKNIS PEKER!AAN (TEMPLATE SWAKELOLA - 9) &orma8 Gam'ar : A1"A!

74 LOKASI

GAMBAR

(TAHUN) DIGAMBAR DIPERIKSA DISETUJUi

PPK………..

(23)

M3n<38a=>i M3n?38>5>i

P3n<a@a7 P35a'a8P3m'>a8Komi8m3n

 NIP 99999999999

99999999999999  NIP 9999999

(24)

(25)

Lampiran ; : !ADUAL PENGADAAN"KEUTU2AN A2AN7 TENAGA KER!A7 DAN PERALATAN (TEMPLATE SWAKELOLA - ;)

(26)

K"L"D"I :  P343r5aan : 

Sa8>an 43r5a"SNT :  Ta=>n An<<aran : 

78

APR MEI !UN !UL AUG SEP O6T NO< DE6 !AN FE MAR KETERANGAN

1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ E,I%LES"KENDARAAN 99999999999 99999999999 99999999999 EFUIPMENT"PERALATAN 99999999999 99999999999 99999999999 MATERIAL"#A,AN 99999999999 99999999999 TENAGA KERA"LA#OUR 99999999999 99999999999

(27)

P343r5aan :  Ta=>n An<<aran : 

No# !ENIS PEKER!AAN 6ARA

PERAIK AN SATU AN KUAN TITAS AWAL KUAN TITAS R6N PEL# 2ARGA SATUAN IA8A SU TOTAL I

(28)

KOP SURAT

KEPUTUSAN KEPALA SATUAN KER!A

KEGIATAN ################################################################## SATUAN KER!A ###################################################################### ####################################################################################################### DEPARTEMEN #################################### NOMOR : ################################### TENTANG

PENGANGKATAN PANITIA PENGADAAN KEGIATAN SWAKELOLA KEGIATAN #################################################################### #############################################################################################

K"L"D"I################################### TA2UN ANGGARAN ########

M$nim3an% : a #a=@a ;a6am ran<4a p36a47anaan K3<ia8an S@a436o6a  K"L"D"I Ta=>n An<<aran  836a= ;ipro<ram4an K3<ia8an C ' #a=@a para P35a'a8"P38><a7 ;i'a@a= ini ;ipan;an< mamp> ;an m3m3n>=i 7?ara8 >n8>4 ;i8>n5>4 ;an ;ian<4a8 73'a<ai Pani8ia P3n<a;aan pa;a Sa8>an K3r5a;i Lin<4>n<anC  #a=@a >n8>4 ma47>; 83r73'>8 ma4a p3r6> ;i838ap4an ;3n<an K3p>8>7an

K3pa6a Sa8>an K3r5a999999999 999999999999999C

M$n%in%a+ : 1 P3ra8>ran Pr37i;3n R3p>'6i4 In;on37ia no $ Ta=>n 2010 83n8an< P3n<a;aan 'aran<"a7a P3m3rin8a=C

2 K3p>8>7anC ! 99999999999999999999999999999999999 999C $ 999999999999999999999999999999999999;78 M E M U T U S K A N M$n$+apan :

(29)

K$+*a

 S$r$+ari,

0 An%%o+a

5 D,+

K$4*a : T><a7 ;an 8an<<>n< 5a@a' Pani8ia P3n<a;aan 73'a<ai '3ri4>8 : 1 m3n?>7>n r3nana p3mi6i=an P3n?3;ia #aran<"a7aC

2 m3n38ap4an Do4>m3n P3n<a;aanC

! m3n38ap4an '37aran nomina6 aminan P3na@aranC

$ m3n<>m>m4an p36a47anaan P3n<a;aan #aran<"a7a ;i @3'7i83 K"L"D"I ma7in<-ma7in< ;an papan p3n<>m>man r37mi >n8>4 ma7?ara4a8 73r8a m3n?ampai4an 43 LPSE >n8>4 ;i>m>m4an ;a6am Por8a6 P3n<a;aan Na7iona6C

 m3ni6ai 4>a6ifi4a7i P3n?3;ia #aran<"a7a m36a6>i pra4>a6ifi4a7i a8a> pa7a4>a6ifi4a7iC

* m36a4>4an 3a6>a7i a;mini78ra7i 834ni7 ;an =ar<a 83r=a;ap p3na@aran ?an< ma7>4C

+ m3n5a@a' 7an<<a=anC

. m3n38ap4an P3n?3;ia #aran<"a7a >n8>4:

i P3636an<an a8a> P3n>n5>4an Lan<7>n< >n8>4 pa438 P3n<a;aan #aran<"P343r5aan Kon78r>47i"a7a Lainn?a ?an< '3rni6ai pa6in< 8in<7 mi6iar r>pia=)C a8a>

ii S36347i a8a> P3n>n5>4an Lan<7>n< >n8>4 pa438 P3n<a;aan a7a Kon7>68an7i ?an< '3rni6ai pa6in< 8in<6>= mi6iar r>pia=)C

/ m3n?3ra=4an 7a6inan Do4>m3n P3mi6i=an P3n?3;ia #aran<"a7a 43pa;a PPKC

10 m3n?impan ;o4>m3n a76i p3mi6i=an P3n?3;ia #aran<"a7aC

11 m3m'>a8 6aporan m3n<3nai pro737 ;an =a7i6 P3n<a;aan 43pa;a M3n83ri"Pimpinan L3m'a<a"K3pa6a Da3ra="Pimpinan In78i8>7iC ;an

12 m3m'3ri4an p3r8an<<>n<5a@a'an a8a7 p36a47anaan 43<ia8an P3n<a;aan #aran<"a7a 43pa;a PA"KPA

1! m3n<>7>64an 43pa;a PPK p3r>'a=an ,PSC ;an"a8a> p3r>'a=an 7p37ifi4a7i 834ni7 p343r5aan apa'i6a ;ian<<ap p3r6>

(30)

43pa7a 43pa6a Sa8>an K3r5a ;an P35a'a8 ?an< m36a4>4an 8in;a4an ?an< m3n<a4i'a84an p3n<36>aran an<<aran '36an5a ;ima7in<-ma7in< 43<ia8an 2 Pani8ia P3n<a;aan 73<3ra m36a47ana4an 8><a7n?a 73836a= 7>ra8 43p>8>7an

ini ;i436>ar4an

! T><a7 pani8ia p3n<a;aan '3ra4=ir pa;a 7aa8 4on8ra4"7>ra8 p3r5an5ian 43r5a ;i8an;a8an<ani o63= 43;>a '36a= pi=a4

K$$mpa+ : K3pa;a pani8ia p3n<a;aan ;i'3ri4an =onorari>m 737>ai 43;>;>4ann?a ;a6am 8im ;an '3r;a7ar4an p3n><a7an ?an< '3r7an<4>8an 73'a<aimana ;i838ap4an m36a6>i S>ra8 P3rin8a= T><a7 (SPT) ;3n<an 4383n8>an p3ra8>ran p3r>n;an<->n;an<an ?an< '3r6a4>

K$'ima : S3<a6a 'ia?a 73'a<ai a4i'a8 ;i6a47ana4ann?a 43p>8>7an ini ;i'3'an4an pa;a An<<aran K3<ia8an  Sa8>an K3r5a 

K"L"D"I  Ta=>n An<<aran C

K$$nam : K3p>8>7an ini '3r6a4> 735a4 8an<<a6 ;i838ap4an ;3n<an 4383n8>an 'a=@a apa'i6a ;i43m>;ian =ari 83r;apa8 43436ir>an ;a6am p3n38apan ini a4an ;ia;a4an p3r'ai4an

DITETAPKAN DI : ########################### PADA TANGGAL : &&&&&&&&##

K$pa'a Sa+*an K$r.a

99999999999999999 NIP 99999999

TEM#USAN S>ra8 P3n><a7an ini ;i7ampai4an 43pa;a 8= :

1 999999999999999999999

(31)

6ATATAN KONDISI DAN 2ASIL PENGUKURAN PROPINSI :999999999 TANGGAL SURAI :999999999999 SATKER"SATKER NT :999999999 %UA%A :999999999999 LOKASI :99999999999 NO STA (4m) KATEGORI KERUSAKAN KETERANGAN PETUGAS (9999999999999 )

NAMA SATUAN KERJA ...

(32)

(TEMPLATE SWAKELOLA - 1?3)

6ATATAN KONDISI DAN 2ASIL SUR<EI

PROPINSI :999999999

TANGGAL SUREI :999999999999 SATKER"SATKER NT :999999999

%UA%A :999999999999

LOKASI :99999999999

NO KEGIATAN URAIAN KEGIATAN KETERANGAN

PETUGAS

NAMA SATUAN KERJA ...

...

(33)

KOP SURAT

Nomor : ……….., ..………

Lamira! : " K#a$a %&'.:

P#!!a A!ara!*P#+aa& P#ma& Komi&m#!

K#ia&a! ……… ……….

$i

………

P#ri'a- : Permohonan Pengajuan Kebutuhan Bahan/Material, Tenaga Kerja, an Peralatan

B#rama i!i $iamai/a! a'0a !&/ m#!$/! /#&'a! a/a! P#!a$aa!………. !&/ S K#ia&a! ……….. a$a K#ia&a! ………., a$a Ta'! A!ara! ………., /ami mo'o! a!&a! /ira!1a /ami $aa& m#r#a-iai/a! #!a$aa! #aai #ri/& :

NO NAMA SATUAN 2OLUME KETERANGAN

3

Ba'a!*Ma&#ria-4 T#!aa K#r+a

5 P#ra-a&a!

D#mi/ia! a&a a!&a!!1a, /ami 6a/a! &#rima /ai'.

Tim P#-a/a!a S0a/#-o-a

K#ia&a!………. ………..

(34)

(TEMPLATE SWAKELOLA - 1a)

KOP SURAT

SURAT PER!AN!IAN

>n8>4 m36a47ana4an

Pa438 P343r5aan P3n<a;aan #aran< 

Nomor: 

Hi4a P3n?3;ia '>4an '3r'3n8>4 43mi8raan"KSO ma4a 4a6ima8 p3m'>4aan"4ompari7i 73'a<ai '3ri4>8:

SURAT PERANIAN ini '3ri4>8 73m>a 6ampirann?a (736an5>8n?a ;i73'>8 Kon8ra4B) ;i'>a8 ;an ;i8an;a8an<ani ;i  pa;a =ari  8an<<a6  '>6an  8a=>n  H8an<<a6 '>6an ;an 8a=>n ;ii7i ;3n<an =>r>f an8ara  Hnama P35a'a8 P3m'>a8 Komi8m3n 736a4> P35a'a8 P3m'>a8 Komi8m3n ?an< '3r8in;a4 >n8>4 ;an a8a7 nama  Hnama 7a8>an 43r5a P35a'a8 P3m'>a8 Komi8m3n ?an< '3r43;>;>4an ;i 

Ha6ama8 P35a'a8 P3m'>a8 Komi8m3n '3r;a7ar4an S>ra8 K3p>8>7an  Hp35a'a8 ?an< m3nan;a8an<ani SK p3n38apan 73'a<ai PPK No  HNo SK p3n38apan 73'a<ai P35a'a8 P3m'>a8 Komi8m3n (736an5>8n?a ;i73'>8  PPK B) ;an  Hnama @a4i6 P3n?3;ia  H5a'a8an @a4i6 P3n?3;ia ?an< '3r8in;a4 >n8>4 ;an a8a7 nama  Hnama P3n?3;ia ?an< '3r43;>;>4an ;i  Ha6ama8 P3n?3;ia '3r;a7ar4an A48a No8ari7 No  HNo A48a no8ari7 8an<<a6  H8an<<a6 p3n3r'i8an A48a ?an< ;i436>ar4an o63= No8ari7  Hnama No8ari7 p3n3r'i8 A48a (736an5>8n?a ;i73'>8  P$n@$4ia B)

Hi4a P3n?3;ia '3r'3n8>4 43mi8raan"KSO ma4a 4a6ima8 p3m'>4aan"4ompari7i 73'a<ai '3ri4>8:

SURAT PERANIAN ini '3ri4>8 73m>a 6ampirann?a (736an5>8n?a ;i73'>8 Kon8ra4B) ;i'>a8 ;an ;i8an;a8an<ani ;i  pa;a =ari  8an<<a6  '>6an  8a=>n  H8an<<a6 '>6an ;an 8a=>n ;ii7i ;3n<an =>r>f an8ara  Hnama P35a'a8 P3m'>a8 Komi8m3n 736a4> P35a'a8 P3m'>a8 Komi8m3n ?an< '3r8in;a4 >n8>4 ;an a8a7 nama  Hnama 7a8>an 43r5a P35a'a8 P3m'>a8 Komi8m3n ?an< '3r43;>;>4an ;i 

Ha6ama8 P35a'a8 P3m'>a8 Komi8m3n '3r;a7ar4an S>ra8 K3p>8>7an  Hp35a'a8 ?an< m3nan;a8an<ani SK p3n38apan 73'a<ai PPK No  HNo SK p3n38apan 73'a<ai P35a'a8 P3m'>a8 Komi8m3n (736an5>8n?a ;i73'>8  PPK B) ;an 43mi8raan"KSO ?an< '3ran<<o8a4an 73'a<ai '3ri4>8:

1  Hnama P3n?3;ia 1C 2  Hnama P3n?3;ia 2C  ;78

?an< ma7in<-ma7in< an<<o8an?a '3r8an<<>n< 5a@a' 73ara pri'a;i ;an 8an<<>n< r3n83n< a8a7 73m>a 43@a5i'an 83r=a;ap PPK '3r;a7ar4an Kon8ra4 ini ;an 836a= m3n>n5>4  Hnama an<<o8a 43mi8raan ?an< ;i8>n5>4 73'a<ai @a4i6 43mi8raan"KSO >n8>4 '3r8in;a4 a8a7 nama K3mi8raan ?an< '3r43;>;>4an ;i  Ha6ama8 P3n?3;ia @a4i6 43mi8raan '3r;a7ar4an

(35)

S?ara8-S?ara8 Um>m Kon8ra4 ?an< 83r6ampir ;a6am Kon8ra4 ini (736an5>8n?a ;i73'>8 P$$r.aan P$n%a4aan aran%B)C

(') P3n?3;ia 73'a<aimana ;in?a8a4an 43pa;a PPK m3mi6i4i 43a=6ian prof37iona6 p3r7oni6 ;an 7>m'3r ;a?a 834ni7 73r8a 836a= m3n?38>5>i >n8>4 m3n?3;ia4an #aran< 737>ai ;3n<an p3r7?ara8an ;an 4383n8>an ;a6am Kon8ra4 iniC

() PPK ;an P3n?3;ia m3n?a8a4an m3mi6i4i 43@3nan<an >n8>4 m3nan;a8an<ani Kon8ra4 ini ;an m3n<i4a8 pi=a4 ?an< ;i@a4i6iC

(;) PPK ;an P3n?3;ia m3n<a4>i ;an m3n?a8a4an 'a=@a 73=>'>n<an ;3n<an p3nan;a8an<anan Kon8ra4 ini ma7in<-ma7in< pi=a4:

1) 836a= ;an 73nan8ia7a ;i'3ri4an 4373mpa8an >n8>4 ;i;ampin8C

!) 836a= m3m'aa ;an m3ma=ami 73ara p3n>= 4383n8>an Kon8ra4 iniC

$) 836a= m3n;apa84an 4373mpa8an ?an< m3ma;ai >n8>4 m3m3ri47a ;an m3n<4onfirma7i4an 73m>a 4383n8>an ;a6am Kon8ra4 ini '373r8a 73m>a fa48a ;an 4on;i7i ?an< 83r4ai8

MAKA OLE, KARENA ITU PPK ;an P3n?3;ia ;3n<an ini '3r73pa4a8 ;an m3n?38>5>i =a6-=a6 73'a<ai '3ri4>8:

1 H>n8>4 4on8ra4 =ar<a 7a8>an a8a> 4on8ra4 <a'>n<an =ar<a 7a8>an ;an 6>mp 7>m ;i8>6i7 73'a<ai '3ri4>8 :

8o8a6 =ar<a Kon8ra4 a8a> Ni6ai Kon8ra4 83rma7>4 Pa5a4 P3r8am'a=an Ni6ai (PPN) ?an< ;ip3ro63= '3r;a7ar4an 4>an8i8a7 ;an =ar<a 7a8>an p343r5aan 73'a<aimana 83ran8>m ;a6am Daf8ar K>an8i8a7 ;an ,ar<a a;a6a= 73'37ar Rp ( r>pia=)CB

H>n8>4 4on8ra4 6>mp 7>m ;i8>6i7 73'a<ai '3ri4>8:

8o8a6 =ar<a Kon8ra4 a8a> Ni6ai Kon8ra4 83rma7>4 Pa5a4 P3r8am'a=an Ni6ai (PPN) a;a6a= 73'37ar Rp ( r>pia=)CB

2 p3ri78i6a=an ;an >n<4apan ;a6am S>ra8 P3r5an5ian ini m3mi6i4i ar8i ;an ma4na ?an< 7ama 73p3r8i ?an< 83ran8>m ;a6am 6ampiran S>ra8 P3r5an5ian iniC

! ;o4>m3n-;o4>m3n '3ri4>8 m3r>pa4an 7a8>-437a8>an ;an 'a<ian ?an< 8i;a4 83rpi7a=4an ;ari Kon8ra4 ini:

a

a;3n;>m S>ra8 P3r5an5ianC

'

po4o4 p3r5an5ianC



7>ra8 p3na@aranC

;

;af8ar 4>an8i8a7 ;an =ar<a (apa'i6a a;a)C

3

7?ara8-7?ara8 4=>7>7 Kon8ra4C

f

7?ara8-7?ara8 >m>m Kon8ra4C

<

7p37ifi4a7i 4=>7>7C

=

7p37ifi4a7i >m>mC

i

<am'ar-<am'arC ;an

(36)

p3r83n8an<an an8ara 4383n8>an ;a6am 7>a8> ;o4>m3n ;3n<an 4383n8>an ;a6am ;o4>m3n ?an< 6ain ma4a ?an< '3r6a4> a;a6a= 4383n8>an ;a6am ;o4>m3n ?an< 63'i= 8in<r>8an =i3rar4i pa;a an<4a ! ;i a8a7C

 ,a4 ;an 43@a5i'an 8im'a6-'a6i4 PPK ;an P3n?3;ia ;in?a8a4an ;a6am Kon8ra4 ?an< m36ip>8i 4=>7>7n?a:

a. _{PPK m3mp>n?ai =a4 ;an 43@a5i'an >n8>4:}

1) m3n<a@a7i ;an m3m3ri47a p343r5aan ?an< ;i6a47ana4an o63= P3n?3;iaC

2) m3min8a 6aporan-6aporan m3n<3nai p36a47anaan p343r5aan ?an< ;i6a4>4an o63= P3n?3;iaC

!) m3m'3ri4an fa7i6i8a7 '3r>pa 7arana ;an pra7arana ?an< ;i'>8>=4an o63= P3n?3;ia >n8>4 436anaran p36a47anaan p343r5aan 737>ai 4383n8>an Kon8ra4C

$) m3m'a?ar p343r5aan 737>ai ;3n<an =ar<a ?an< 83ran8>m ;a6am Kon8ra4 ?an< 836a= ;i838ap4an 43pa;a P3n?3;iaC

b. _{P3n?3;ia m3mp>n?ai =a4 ;an 43@a5i'an >n8>4:}

1) m3n3rima p3m'a?aran >n8>4 p36a47anaan p343r5aan 737>ai ;3n<an =ar<a ?an< 836a= ;i83n8>4an ;a6am Kon8ra4C

2) m3min8a fa7i6i8a7-fa7i6i8a7 ;a6am '3n8>4 7arana ;an pra7arana ;ari PPK >n8>4 436anaran p36a47anaan p343r5aan 737>ai 4383n8>an Kon8ra4C

!) m36apor4an p36a47anaan p343r5aan 73ara p3rio;i4 43pa;a PPK C

$) m36a47ana4an ;an m3n?3637ai4an p343r5aan 737>ai ;3n<an 5a;@a6 p36a47anaan p343r5aan ?an< 836a= ;i838ap4an ;a6am Kon8ra4C

) m36a47ana4an ;an m3n?3637ai4an p343r5aan 73ara 3rma8 a4>ra8 ;an p3n>= 8an<<>n< 5a@a' ;3n<an m3n?3;ia4an 83na<a 43r5a 'a=an-'a=an p3ra6a8an an<4>8an 43 a8a> ;ari 6apan<an ;an 73<a6a p343r5aan p3rman3n ma>p>n 73m3n8ara ?an< ;ip3r6>4an >n8>4 p36a47anaan p3n?3637aian ;an p3r'ai4an p343r5aan ?an< ;irini ;a6am Kon8ra4C

*) m3m'3ri4an 4383ran<an-4383ran<an ?an< ;ip3r6>4an >n8>4 p3m3ri47aan p36a47anaan ?an< ;i6a4>4an PPKC

+) m3n?3ra=4an =a7i6 p343r5aan 737>ai ;3n<an 5a;@a6 p3n?3ra=an p343r5aan ?an< 836a= ;i838ap4an ;a6am Kon8ra4C

.) m3n<am'i6 6an<4a=-6an<4a= ?an< >4>p m3ma;ai >n8>4 m36in;>nn<an 83mpa8 43r5a ;an m3m'a8a7i p3r>7a4an ;an <an<<>an 43pa;a ma7?ara4a8 ma>p>n mi6i4n?a a4i'a8 43<ia8an P3n?3;ia

* Kon8ra4 ini m>6ai '3r6a4> 3f348if 83r=i8>n< 735a4 8an<<a6 ?an< ;i838ap4an ;a6am S?ara8-S?ara8 Um>m"K=>7>7 Kon8ra4 ;3n<an 8an<<a6 m>6ai ;an p3n?3637aian 43736>r>=an p343r5aan 73'a<aimana ;ia8>r ;a6am S?ara8-S?ara8 Um>m"K=>7>7 Kon8ra4

(37)

Un8>4 ;an a8a7 nama  PPK

H8an;a 8an<an ;an ap (5i4a 7a6inan a76i ini >n8>4 P3n?3;ia ma4a r34a84an ma83rai Rp *000- )

Hnama 63n<4ap  H5a'a8an

Un8>4 ;an a8a7 nama P3n?3;ia" 43mi8raan (KSO) 

H8an;a 8an<an ;an ap (5i4a 7a6inan a76i ini >n8>4 7a8>an 43r5a PPK ma4a r34a84an ma83rai Rp

*000- )

Hnama 63n<4ap H5a'a8an