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REQUEST FOR CERTIFICATE OF T{O IITIPRO\GUENT

Conbol Number/ Dalo

Th€ City As66ssor


City ol Dasmeiflas

I heraby requost your good offco ftr h6 i8suance ol cgrlifrab of no imp.o\€mont


D6clarod Owner

Location of Prop6rty

Mailing Addess

Tax Doc. No. ol Land

Dat6 and Tim6 of lns@lion

Docum6nb Prosenbd/gJbmiurd:
z/. riu (ptrotoopy)
tax doaranoo- Room 108 City Hall - O1010c0ry
, Sketch going to tha pDperty
-4cunantyar Sder/Donation Eto., Contrad to Sell, (Authority on -
Land) ftofOcofy
no oopy ol bx dodratim of LalG Assosso.s
c*tnoO ofiao - fllof0(rpY
-lWot
,lf not th6 Oruner- Specid Power of Attorn€y dl ynp I p
-/.
_7. For Corporation- SEC Registratbn, Adiies of lnooporation, Seoetarys Certifoate
Eafaymont F66. Php 400.m
others

Rsnal(s
- Pnnlod NetE 6nd Strnet e

ilob Plos6 Dl'iC d arlllC capy d 0B abqa nrton d Co0Ld llo


(bql.rBlatrvsii,lo,l

ACKNOWLEDGIEiIT RECEIPT
REOUEST FOR CERNFICATE OF I{O If,PROVETEI{T

Contol Number/ Dah

Decbad Orner
Locatirn ol Rop€rty

Tax Doc l,lo. ot Land

Dab of ln6p6ctbn

Date of Released ol CertifE8ton

canmt act rarrdrbty on yotr rs$€sl.


Reason:

R@v€d by/ Dal€

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