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["福セ評申－05"]
[]
[{"$nulls":8},"建設住宅性能評価申請書",{"$nulls":8},"（新築住宅）"]
[null,"（第一面）"]
[]
[]
[{"$nulls":16},"令和",null,null,"年",null,"月",null,"日"]
[]
[]
["一般財団法人福岡県建築住宅センター　殿"]
[]
[]
[]
[{"$nulls":11},"申請者の氏名又は名称"]
{"$rows_empty":8}
[null,"　住宅の品質確保の促進等に関する法律第５条第1項の規定に基づき、建設住宅性能評価を申請します。"]
[]
[null,"この申請書及び添付図書に記載の事項は、事実に相違ありません。"]
[]
[]
[]
[]
[null,null,"工事施工者の氏名及び名称："]
[]
[]
[{"$nulls":9},"代表者の氏名"]
[null,null,"工事監理者の氏名："]
[]
[]
[{"$nulls":12},"氏名"]
{"$rows_empty":10}
[null,"※受付欄",{"$nulls":5},"　※料金欄"]
[null,null,"年",null,"月",null,"日"]
[null,"第",{"$nulls":4},"号"]
[null,"申請受理者氏名"]

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[]
[null,"（第二面）"]
["申請者等の概要"]
["【1.申請者】"]
[null,null,null,"フリガナ","："]
[]
[null,null,null,"氏名又は名称","："]
[]
[null,null,null,"〒","："]
[]
[null,null,null,"住所","："]
[]
[null,null,null,"電話番号","："]
["【2.代理者】"]
[null,null,null,"フリガナ","："]
[]
[null,null,null,"氏名又は名称","："]
[]
[null,null,null,"〒","："]
[]
[null,null,null,"住所","："]
[]
[null,null,null,"電話番号","："]
["【3.建築主】"]
[null,null,null,"フリガナ","："]
[]
[null,null,null,"氏名又は名称","："]
[]
[null,null,null,"〒","："]
[]
[null,null,null,"住所","："]
[]
[null,null,null,"電話番号","："]
["【4.設計者】"]
[null,null,null,"資格","：",{"$nulls":6},"：",{"$nulls":5},"第",{"$nulls":6},"号"]
[]
[null,null,null,"氏名","："]
[]
[null,null,null,"建築士事務所名","："]
[]
[{"$nulls":11},"：","福岡県知事",null,null,"登録",null,"第",{"$nulls":6},"号"]
[]
[null,null,null,"〒","："]
[]
[null,null,null,"所在地","："]
[]
[null,null,null,"電話番号","："]
["【5.工事監理者】"]
[null,null,null,"資格","：",{"$nulls":6},"：",{"$nulls":5},"第",{"$nulls":6},"号"]
[]
[null,null,null,"氏名","："]
[]
[null,null,null,"建築士事務所名","："]
[]
[{"$nulls":11},"：","福岡県知事",null,null,"登録",null,"第",{"$nulls":6},"号"]
[]
[null,null,null,"〒","："]
[]
[null,null,null,"所在地","："]
[]
[null,null,null,"電話番号","："]
["【6.工事施工者】"]
[null,null,null,"氏名及び名称","："]
[]
[null,null,null,"営業所","：",null,null,null,"建築業の許可","：","福岡県知事許可",null,null,null,"（","般","-",null,")","第",null,null,null,"号"]
[]
[null,null,null,"〒","："]
[]
[null,null,null,"所在地","："]
[]
[null,null,null,"電話番号","："]
["【7.建設住宅性能評価を希望する性能表示事項】"]
{"$rows_empty":12}
["【8.備考】"]

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[]
[{"$nulls":30},"第二面（別紙）"]
[]
[null,null,"【建設住宅性能評価を希望する性能表示事項】"]
[null,null,"１．構造の安定に関すること"]
[null,null,"□",null,"１－２　耐震等級（構造躯体の損傷防止）"]
[null,null,"□",null,"１－４　耐風等級（構造躯体の倒壊等防止及び損傷防止）"]
[null,null,"□",null,"１－５　耐積雪等級（構造躯体の倒壊等防止及び損傷防止）"]
[]
[null,null,"２．火災時の安全に関すること"]
[null,null,"□",null,"２－１　感知警報装置設置等級（自住戸火災時）"]
[null,null,"□",null,"２－４　脱出対策（火災時）"]
[null,null,"□",null,"２－５　耐火等級（延焼のおそれのある部分（開口部））"]
[null,null,"□",null,"２－６　耐火等級（延焼のおそれのある部分（開口部以外））"]
[null,null,"□",null,"２－７　耐火等級（界壁及び界床）"]
[]
[null,null,"６．空気環境に関すること"]
[null,null,"□",null,"６－１　ホルムアルデヒド対策（内装及び天井裏等）"]
[null,null,"□",null,"６－２　換気対策"]
[null,null,"□",null,"６－３　室内空気中の化学物質の濃度等"]
[{"$nulls":9},"特定測定物質（必須）　ホルムアルデヒド"]
[{"$nulls":9},"特定測定物質（選択）　",{"$nulls":11},"□トルエン　□キシレン　□エチルベンゼン　□スチレン"]
[]
[null,null,"７．光・視環境に関すること"]
[null,null,"□",null,"７－１　単純開口率"]
[null,null,"□",null,"７－２　方位別開口比"]
[]
[null,null,"８．音環境に関すること"]
[null,null,"□",null,"８－４　透過損失等級（外壁開口部）"]
[]
[null,null,"９．高齢者等への配慮に関すること"]
[null,null,"□",null,"９－１　高齢者等配慮対策等級（専用部分）"]
[]
[null,null,"１０．防犯に関すること"]
[null,null,"□",null,"１０－１　開口部の侵入防止対策"]
[]
[]
[null,null,"（注意）"]
[{"$nulls":4},"①",null,"選択を希望する性能表示事項にチェックしてください。"]
[]
[null,null,null,"【地盤の液状化に関する情報提供】"]
[null,null,null,"□",null,"地盤の液状化に関する情報提供を行う（情報提供の内容は申出書による）"]
[null,null,null,"□",null,"地盤の液状化に関する情報提供を行わない"]
[]
[null,null,null,"（注意）"]
[{"$nulls":5},"情報提供について、いずれかにチェックしてください。"]

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[]
[{"$nulls":30},"第二面（別紙）"]
[]
[null,null,"【建設住宅性能評価を希望する性能表示事項】"]
[null,null,"１．構造の安定に関すること"]
[null,null,"□",null,"１－２　耐震等級（構造躯体の損傷防止）"]
[null,null,"□",null,"１－４　耐風等級（構造躯体の倒壊等防止及び損傷防止）"]
[null,null,"□",null,"１－５　耐積雪等級（構造躯体の倒壊等防止及び損傷防止）"]
[]
[null,null,"２．火災時の安全に関すること"]
[null,null,"□",null,"２－１　感知警報装置設置等級（自住戸火災時）"]
[null,null,"□",null,"２－２　感知警報装置設置等級（他住戸火災時）"]
[null,null,"□",null,"２－３　避難安全対策（他住戸等火災時・共用廊下）"]
[null,null,"□",null,"２－４　脱出対策（火災時）"]
[null,null,"□",null,"２－５　耐火等級（延焼のおそれのある部分（開口部））"]
[null,null,"□",null,"２－６　耐火等級（延焼のおそれのある部分（開口部以外））"]
[null,null,"□",null,"２－７　耐火等級（界壁及び界床）"]
[]
[null,null,"４．維持管理・更新への配慮に関すること"]
[null,null,"□",null,"４－４　更新対策（住戸専用部）"]
[]
[null,null,"６．空気環境に関すること"]
[null,null,"□",null,"６－１　ホルムアルデヒド対策（内装及び天井裏等）"]
[null,null,"□",null,"６－２　換気対策"]
[null,null,"□",null,"６－３　室内空気中の化学物質の濃度等"]
[{"$nulls":9},"特定測定物質（必須）　ホルムアルデヒド"]
[{"$nulls":9},"特定測定物質（選択）　",{"$nulls":11},"□トルエン　□キシレン　□エチルベンゼン　□スチレン"]
[]
[null,null,"７．光・視環境に関すること"]
[null,null,"□",null,"７－１　単純開口率"]
[null,null,"□",null,"７－２　方位別開口比"]
[]
[null,null,"８．音環境に関すること"]
[null,null,"□",null,"８－１　重量床衝撃音対策"]
[null,null,"□",null,"８－２　軽量床衝撃音対策"]
[null,null,"□",null,"８－３　透過損失等級（界壁）"]
[null,null,"□",null,"８－４　透過損失等級（外壁開口部）"]
[]
[null,null,"９．高齢者等への配慮に関すること"]
[null,null,"□",null,"９－１　高齢者等配慮対策等級（専用部分）"]
[null,null,"□",null,"９－２　高齢者等配慮対策等級（共用部分）"]
[]
[null,null,"１０．防犯に関すること"]
[null,null,"□",null,"１０－１　開口部の侵入防止対策"]
[]
[null,null,"（注意）"]
[{"$nulls":4},"①",null,"選択を希望する性能表示事項にチェックしてください。"]
[]
[null,null,null,"【地盤の液状化に関する情報提供】"]
[null,null,null,"□",null,"地盤の液状化に関する情報提供を行う（情報提供の内容は申出書による）"]
[null,null,null,"□",null,"地盤の液状化に関する情報提供を行わない"]
[]
[null,null,null,"（注意）"]
[{"$nulls":5},"情報提供について、いずれかにチェックしてください。"]

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[]
[null,"（第三面）"]
["申請する工事の概要"]
["【1.建築場所】"]
[]
[]
["【2.設計住宅性能評価書の交付番号】"]
[]
[]
["【3.設計住宅性能評価書の交付年月日】"]
[{"$nulls":12},"年",null,"月",null,"日",{"$nulls":12},"※西暦でご記入ください"]
[]
["【4.設計住宅性能評価書の交付者】"]
[]
[]
["【5.確認済証番号】"]
[]
[]
["【6.確認済証交付年月日】"]
[{"$nulls":12},"年",null,"月",null,"日",{"$nulls":12},"※西暦でご記入ください"]
[]
["【7.確認済証交付者】"]
[{"$nulls":8},"一般財団法人　福岡県建築住宅センター　理事長"]
[]
["【8.工事着手（予定）年月日】"]
[{"$nulls":12},"年",null,"月",null,"日",{"$nulls":12},"※西暦でご記入ください"]
[]
["【9.工事完了予定年月日】"]
[{"$nulls":12},"年",null,"月",null,"日",{"$nulls":12},"※西暦でご記入ください"]
[]
["【10.検査対象工程工事終了予定年月日】"]
[null,null,null,"（第１回）",{"$nulls":6},"年",null,"月",null,"日","検査時期",null,null,"基礎配筋工事完了時",{"$nulls":10},"←検査の工程を先に選択してください"]
[]
[null,null,null,"（第２回）",{"$nulls":6},"年",null,"月",null,"日","検査時期",null,null,"躯体工事完了時"]
[]
[null,null,null,"（第３回）",{"$nulls":6},"年",null,"月",null,"日","検査時期",null,null,"下地張り直前工事完了時"]
[]
[null,null,null,"（第４回）",{"$nulls":6},"年",null,"月",null,"日","検査時期",null,null,"竣工時"]
[]
[null,null,null,"",{"$nulls":6},"",null,"",null,"",""]
[]
[null,null,null,"",{"$nulls":6},"",null,"",null,"",""]
[]
[null,null,null,"",{"$nulls":6},"",null,"",null,"",""]
[]
[null,null,null,"",{"$nulls":6},"",null,"",null,"",""]
[]
[]
[]
["【11.その他必要な事項】"]
[]
[]
[]
["【12.備考 】"]
{"$rows_empty":32}
[null,null,"検査時期"]
[]
[null,null,"基礎配筋工事完了時"]
[null,null,"躯体工事完了時"]
[null,null,"２階の床躯体工事完了時"]
[null,null,"10階の床躯体完了時"]
[null,null,"下地張り直前工事完了時"]
[null,null,"屋根工事完了時"]
[null,null,"竣工時"]
[null,null,"内装仕上げ工事完了時"]

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[]
[null,"（注意）"]
[null,"１．第一面関係"]
[null,"　　※印のある欄は記入しないでください。"]
[null,"２．第二面関係"]
[null,"　①　申請者からの委任を受けて申請を代理で行う者がいる場合においては、２欄に記入してください。"]
[null,"　②　申請者が２以上のときは、１欄には代表となる申請者のみについて記入し、別紙に他の申請者について"]
[null,"　　それぞれ必要な事項を記入してください。"]
[null,"　③　建築主が２以上のときは、３欄には代表となる建築主のみについて記入し、別紙に他の建築主について"]
[null,"　　それぞれ必要な事項を記入して添えてください。"]
[null,"　④　４欄及び５欄の郵便番号、所在地及び電話番号には、設計者又は工事監理者が建築士事務所に"]
[null,"　　属しているときはそれぞれ建築士事務所のものを、設計者又は工事監理者が建築士事務所に属して"]
[null,"　　いないときはそれぞれ設計者又は工事監理者のもの（所在地は住所とします。）を書いてください。"]
[null,"　⑤　７欄は、「別紙による」と記入し、第二面（別紙）に希望する性能表示事項を記載してください。"]
[null,"　　ただし、７欄に直接希望する性能表示事項を全て記入する場合は第二面（別紙）の提出は不要です。"]
[null,"　　なお、選択事項の全てを希望しない場合は、「希望選択事項なし」等を明示してください。"]
[null,"　　その場合は第二面（別紙）の提出は不要です。"]
[null,"４．第三面関係"]
[null,"　①　１欄は、地名地番と併せて住居表示が定まっているときは、当該住居表示を括弧書きで併記してくださ"]
[null,"　　い。"]
[null,"　②　５欄から７欄までは、確認済証が交付されていない場合は空欄としてください。"]
[null,"　③　８欄は、既に工事を着手している場合はその年月日を、それ以外の場合は予定日の年月日を記入"]
[null,"　　してください。"]
[null,"　④　１０欄は、検査の回数が９回以上の場合は、適宜記入欄を増やして記入してください。"]
[null,"　⑤　ここに書き表せない事項で、評価に当たり特に注意を要する事項は１１欄又は別紙に記載して添えてく"]
[null,"　　ださい。"]
[null,"　⑥　変更建設住宅性能評価に係る申請の際は、１２欄に第三面に係る部分の変更の概要について記入してくだ"]
[null,"　　さい。"]
[null,"備考　１　この用紙の大きさは、日本工業規格A４としてください。"]
[null,"　　　２　第一面は、申請者若しくは工事施工者（法人である場合にあっては、その代表者）又は工事監理者の"]
[null,"　　　　氏名の記載を自署で行う場合においては、押印を省略することができます。"]
[null,"　　　３　第二面及び第三面については、建築確認等他の制度の申請書の写しに必要事項を補こと、複数の住戸"]
[null,"　　　　に関する情報を集約して記載すること等により記載すべき事項のすべてが明示された別の書面をもって"]
[null,"　　　　代えることができます。"]
[null,"　　　４　共同住宅等に係る建設住宅性能評価の申請にあっては、この申請書を共同住宅等一棟又は複数の"]
[null,"　　　　住戸につき一部とすることができます。"]

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[null,null,"　私は、",{"$nulls":20},"を代理人と定め、"]
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[null,null,"下記の物件に関する以下の権限を委任します。"]
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[null,null,1,"委任する事項"]
[{"$nulls":5},"□","設計住宅性能評価",{"$nulls":8},"□","建設住宅性能評価"]
[{"$nulls":5},"□","変更設計住宅性能評価",{"$nulls":8},"□","変更建設住宅性能評価"]
[{"$nulls":5},"□","その他",null,"（",{"$nulls":16},"）"]
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[null,null,2,"委任する内容"]
[{"$nulls":5},"上記１に関する手続き、申請関係図書の訂正及び登録住宅性能評価機関から交付される文書の受領　等"]
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[null,null,3,"物件の内容"]
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[{"$nulls":5},"【住宅又は建築物の名称】"]
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[{"$nulls":5},"【住宅の所在地（地名地番）】"]
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[{"$nulls":20},"令和",null,"年",null,"月",null,"日"]
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[{"$nulls":9},"委任者"]
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