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)
OWNER/APPLICANT LAST NAME FIRST NAME M.I. TIN

FOR CONSTRUCTION OWNED BY FORM OF OWNERSHIP USE OR CHARACTER OF OCCUPANCY

AN ENTERPRISE
ADDRESS NO. STREET, BARANGAY, CITY/MUNICIPALITY ZIP CODE TEL. NO.

LOCATION OF INSTALLATION: LOT NO.: ______________________ BLK NO.: _______________________ TCT NO.: _________________ TAX DEC. NO.: _____________________

STREET: ___________________________________________________________________ BARANGAY: ___________________________________________, QUEZON CITY

SCOPE OF WORK:
NEW CONSTRUCTION RENOVATION RAISING
ERECTION CONVERSION ACCESSORY BUILDING/STRUCTURE
ADDITION REPAIR OTHERS (Specify)
ALTERATION MOVING

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

FIXTURE TO BE INSTALLED
NEW EXISTING KIND OF NEW EXISTING KIND OF
QTY. FIXTURES FIXTURES FIXTURES QTY. FIXTURES FIXTURES FIXTURES

WATER CLOSET BIDETTE

FLOOR DRAIN LAUNDRY TRAYS
LAVATORIES DENTAL CUSPIDOR
KITCHEN SINK DRINKING FOUNTAIN
FAUCET BAR SINK
SHOWER HEAD SODA FOUNTAIN SINK
WATER METER LABORATORY SINK
GREASE TRAP STERILIZER
BATH TUBS SWIMMING POOL
SLOP SINK OTHERS (SPECIFY)

URINAL
AIR CONDITIONING UNIT
WATER TANK/RESERVIOR

TOTAL TOTAL

WATER DISTRIBUTION SYSTEM SEWAGE SYSTEM STORM DRAINAGE 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
DESIGN PROFFESIONAL PLANS AND SPECIFICATION SUPERVISOR IN-CHARGE OF INSTALLATION

Date: Date:
SANITARY ENGINEER/MASTER PLUMBER SANITARY ENGINEER/MASTER PLUMBER
(Signed and Sealed Over Printed Name) (Signed and Sealed Over Printed Name)

Address: Address:

PRC No. Validity PRC No. Validity

PTR No. Date Issued PTR No. Date Issued

Issued at TIN Issued at TIN

BOX 5 BOX 6
BUILDING OWNER / APPLICANT: WITH CONSENT: LOT OWNER

(Signature Over Printed Name) (Signature Over Printed Name)

Date: Date:

Address: Address:

CTC No. Date Issued Place Issued CTC No. Date Issued Place Issued

BOX 7

APPLICANT Date:
(Signature Over Printed Name)

Address:

CTC No. Date Issued Place Issued TIN

QCG-DBO-CPA05-V01