DPWH FORM NO.

96-002-E
REPUBLIC OF THE PHILIPPINES
DEPARTMENT OF PUBLIC WORKS AND
HIGHWAYS
BAGUIO
OFFICE OF THE CITY OFFICIAL
LOCAL BUILDING
DISTRICT/CITY/MUNICIPALITY
AREA CODE 2600
APPLICATION NO. DATE OF APPLICATION FILED

APPLICATION OF ELECTRICAL
Date Of Proposed Start Of Installation PERMIT Expected Date of Completion

BOX 1 (TO BE ACCOMPLISHED BY DULY ELECTRICAL QUALIFIED

PRACTITIONER)
NAME OF OWNER/APPLICANT: LAST NAME FIRST NAME MIDDLE NAME TIN

ADDRESS NO., STREET, BARANGAY, CITY CONTACT NO./EMAIL ADDRESS

BAGUIO
LOCATION OF INSTALLTION: NO., STREET, BARANGAY, CITY
BAGUIO
SCOPE OF WORK ADDITION OF OTHERS (SPECIFY)
NEW INSTALLATION REPAIR OF

ANNUAL INSPECTION REMOVAL OF

TYPE OF OCCUPANCY OR USE:

A. RESIDENTIAL DWELLING E. BUSINESS & MERCANTILE I. ASSEMBLY OCUPANT LOAD 10000 OR
MORE B. RESIDENTIAL, HOTEL, APARTMENT F. INDUSTRIAL J. ACCESSORY
C. EDUCATION & RECREATION G. STORAGE & HAZARDOUS K. OTHERS (SPECIFY0
D. INSTITUTIONAL H. ASSEMBLY OTHERTHAN GROUP 1
NUMBER OF OUTLETS: NUMBER OF EQUIPMENT/WIRING DEVICES:
LIGHT SPO, COOKING UNIT TOGGLE SWITCH FA DETECTORS
CONVENIECE/RECEPTACLE SPO, WATER HEATER BELLS/BUZZERS OTHERS (See Attached list)
SPO, AIRCON SPO, WATER PUMP PUSH BUTTONS

BOX 2 (PROFESSIONAL ELECTRICAL ENGINEER WHO SIGNED AND SEALED PLANS &
SPECOFOCATIONS)

NAME PRC. REG. NO VALIDITY

ADDRESS TEL/FAX NO.
PTR. NO. DATE ISSUED PLACE ISSUED
SIGNATURE DATE SIGNED TIN

BOX 3 (ELECTRICAL CONTRACTOR-200-AMPERE MAIN AND

ABOVE)
NAME (SPECIALTY ELECTRICAL)
PCAB LIC. NO.
PROFESSIONAL ELECTRICAL ENGINEER REGISTERED ELECTRICAL ENGINEER REGISTERED MASTER ELECTRICIAN
VALIDITY (Not Exceeding 600 Volts & 500kVa)
ADRESS NAME SIGNATURE TEL/FAX NO. TIN
NAME PRC. REG. NO. CTC NO.___________________________
VALIDITY
ADDRESS TEL/FAX NO. DATE ISSUED ______________________
BOX 4 (PERSON IN CHARGE OF
PTR. NO.
INSTALLATION) DATE ISSUED PLACE ISSUEDPLACE ISSUED _____________________
SIGNATURE DATE SIGNED TIN

RECEIVED BY: ____________________________________________________________

(SIGNATURE OVER PRINTED NAME)

ELECTRICAL PLANS & SPECIIFICATIONS (5 SETS)

BOX 5 ( OWNER/AUTHORIZED DATE RECEIVED: _________________________________________________________

REPRESENTATIVE)

BOX 6 (TO BE RECEIVED BY RECEIVING/RECORDING

SECTION)