REPUBLIC OF THE PHILIPPINES

QUEZON CITY
DEPARTMENT OF THE BUILDING OFFICIAL

APPLICATION FOR SANITARY/PLUMBING PERMIT

APPLICATION NO.
DATE OF APPLICATION:
BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE OWNER/APPLICANT AND BY THE DESIGN PROFESSIONALS)
LAST NAME
FIRST NAME
M.I.
TIN
OWNER/APPLICANT
FOR CONSTRUCTION OWNED BY
AN ENTERPRISE
NO.

ADDRESS

FORM OF OWNERSHIP
STREET,

LOCATION OF INSTALLATION:

BARANGAY,

LOT NO.: ______________________

STREET: ___________________________________________________________________

USE OR CHARACTER OF OCCUPANCY

CITY/MUNICIPALITY

BLK NO.: _______________________

TEL. NO.

ZIP CODE

TAX DEC. NO.: _____________________

TCT NO.: _________________

BARANGAY: ___________________________________________,

QUEZON CITY

SCOPE OF WORK:
RAISING

RENOVATION

NEW CONSTRUCTION
ERECTION

CONVERSION

ACCESSORY BUILDING/STRUCTURE

ADDITION
ALTERATION

REPAIR
MOVING

OTHERS (Specify)

BOX 2 (TO BE ACCOMPLISHED IN PRINT BY THE DESIGN PROFESSIONAL)

FIXTURE TO BE INSTALLED
KIND OF
FIXTURES

EXISTING
FIXTURES

NEW
FIXTURES

QTY.

NEW
FIXTURES

QTY.

KIND OF
FIXTURES

EXISTING
FIXTURES

WATER CLOSET

BIDETTE

FLOOR DRAIN

LAUNDRY TRAYS

LAVATORIES
KITCHEN SINK

DENTAL CUSPIDOR
DRINKING FOUNTAIN

FAUCET

BAR SINK

SHOWER HEAD

SODA FOUNTAIN SINK

WATER METER
GREASE TRAP

LABORATORY SINK

BATH TUBS

SWIMMING POOL

SLOP SINK

OTHERS (SPECIFY)

STERILIZER

URINAL
AIR CONDITIONING UNIT
WATER TANK/RESERVIOR
TOTAL

TOTAL
WATER DISTRIBUTION SYSTEM

STORM DRAINAGE SYSTEM

SEWAGE SYSTEM

SHALLOW WELL

WASTE WATER TREATMENT PLANT

SURFACE DRAINAGE

DEEP WELL & PUMPSET

IMHOFF TANK

STREET CANAL

CITY/MUNICIPAL WATER SYSTEM

SANITARY SEWER CONNECTION

WATER COURSE

OTHERS (Specify)

SUB-SURFACE SAND FILTER

OTHERS (Specify)

OTHERS (Specify)

PREPARED BY:

BOX 3

BOX 4
SUPERVISOR IN-CHARGE OF INSTALLATION

DESIGN PROFFESIONAL PLANS AND SPECIFICATION

Date:

Date:
SANITARY ENGINEER/MASTER PLUMBER

SANITARY ENGINEER/MASTER PLUMBER

(Signed and Sealed Over Printed Name)

(Signed and Sealed Over Printed Name)

Address:

Address:
Validity

PRC No.

Validity

PTR No.

Date Issued

PTR No.

Date Issued

Issued at

TIN

Issued at

TIN

PRC No.

BOX 5

BOX 6

BUILDING OWNER:

WITH CONSENT: LOT OWNER

(Signature Over Printed Name)

(Signature Over Printed Name)

Date:

Date:

Address:
CTC No.

Address:
Date Issued

Place Issued

CTC No.

Date Issued

Place Issued

BOX 7

Date:

APPLICANT
(Signature Over Printed Name)
Address:
CTC No.

Date Issued

Place Issued

TIN