Republic of the Philippines )

City of ________________ ) Sc.

AFFIDAVIT OF UNDERTAKING

I, _(Name of Owner/Occupant/ /duly authorized representative of the owner/

Officer authorized to execute the undertaking in case of corporation), of legal age and a
resident of _______________________, do hereby depose and state that:

1. I am the (state whether the affiant is the owner/occupant/duly authorized

representative of the owner/position in case of officer of the corporation) of
_(state the name of establishment/building applying for business permit )
located at ______________________________________________.
(Attach the authorization of the owner/occupant in case of representative
or in case of corporation board resolution authorizing the affiant to execute
this affidavit of undertaking)

2. At the time of my application for Business Permit for the said

establishment/building, no substantial changes which may affect the fire
safety compliance or which may change the nature of use or types of
occupancy, or changes on the location of the said establishment/building
have been made from the time it was issued with Fire Safety Inspection
Certificate (FSIC) for Occupancy Permit last (State the date of issuance of
FSIC for Occupancy Permit, which must not be more than 9 months at the
time of the application for Business Permit ).

3. That I am executing this affidavit for the purpose of applying for FSIC for
Business Permit and to attest the truth of the foregoing facts.

In witness whereof, I have hereunto affixed my signature this _____ day of

_(month) (year)_ at __________________.

Affiant Signature

SUBSCRIBE AND SWORN TO before me this ______ day of _(month)

(year)_, affiant exhibiting to me his (State name of government issued valid ID) issued
in the City of ____________ on______________, to expire on _________________ as
competent evidence of identity.

NOTARY PUBLIC

Doc No. _______

Page No._______
Book No._______
Series of _______

BFP-QSF-FSED-028 Rev ØØ (06.01.18)