DPWH ANCILLARY FORM NO 2003-001 -S

Republic of the Philippines

Depa11ment of Public Works & Highways
Pamahalaang Lungsod/Bayan no-"- - -- -
Kalakhan g Maynila/Lalawigan no-a_ __ _ _ __ _

TANGGAPAN NG PINUNONG PANGGUSALJ

(®fficr of tlJr JJ»uilbing C!&ffitial)
PROCESSING AND EVALUATION DIVISION
~a n i ta rp ~ection
SANITARY PERMIT
APPLICATIO N NO . sr NO. B UILDING PERMIT NO.
r I I I I I I I [JJ I l-lr---r-1-.I---.1--rl---.1--.1____,1,---,1
I I I I I I I I [Tl
BOX 1 (TO BE ACCOMPLISHED BT THE OWNER/APPLI CANT)

OW NER/APPILCANT LAST NAME FIRST NAME M.L TI N

FOR CONSTRUCTION OWNED FORM OWNEERSHIP USE OR CHARACTER OF OCCUPANCY

BY AN ENTERPRISE
--
ADDERSS NO., STREET, BARANGAY, CITY/MUNICIPALITY ZIP CODE TELEPHONE NO.

- ---
LOCATION OF CO NSTRUCTIO N LOT NO.
-l:lLK. NO. TCT NO. TAX DEC. NO.

STREET BARANAGAY - - - - CITY /MUNICIPALITY OF

-·
SCOPE OF WORK
0 NEW CONSTRUCTION 0 RENOVATION 0 DEMOLITION
0 ERECTION 0 CONVERSION 0 ACCESSORY BUI LDING/STRUCTURE
0 ADDITIONAL 0 REP/\IH 0 OTHERS (specify)
0 ALTERATION 0 MOVING
- - -- --·· -
BOX 2(TO BE ACCOMPLISHED BY THE DESIGN PROFFESSIONAL)

INSTALLATION AND OPERATION OF:

WATER SUPPLY: SYSTEM OF DISPOSAL:

0 SHALLOW WELL [_:] WASTE WATER TREATM ENT PLANT 0 SURFACE DRAINAGE

0 DEEP WELL & PUMP SET L.] IMHOFF TANK 0 STREET CANAL

0 CITY/MUNICIPAL WATER SYSTEM 0 SANITARY SEWER CONNECTION 0 WATER COURSE

0 OTHERS (Specify) 0 SUB-SU RFACE SAND FILTER 0 OTHERS (Specify) _ _ _ __

PREPARED BY: - - - - - -- - - --

'-------------
BOX3
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BOX4
- ----------------- -----__/
- - ·
DESIGNE PROFESSIONAL, PLANS AND SPECIFICATION ' SUPERVISOR OF SANITARY WORKS
'I

SANITARY ENGINEER SAN ITARY ENGINEER

(Signature Over Printed Name) (Signature Over Printed Name)
·---
Address - Add ress
PRC No. Validity PRC No. Va lidity
- -·
PTR No. Date Issued PTR No. Date Issued
-
Issued at TIN Issued at TIN
_/
'- _/
BOX5 BOX6

BUILDING OWNER W ITH MY CONCERN: LOT OWNER

(Signature Over Printed Nam e) (Signature Over Printed Name)

Address Address

C.T.C. No. Date Issued Place Issued C.T.C. No. Date Issued Place Issued
--'
BOX 7 (SUBMIT TALS TO CHECKE D, RECEIV ED AND
RECOR DED)

RECEIVE D BY:
- -----'-- =D-'-'A-'-'
TE::..::_ _ _ _ _ __ _ _ _ _ __ _ __ _
__ _ -1
FIVE (5) SETS OF SANITA RY DOCUM ENTS
0 SANITAR Y PLANS AN D SPECIFIC ATIONS
0 COST ESTI MATES

0 BILL OF MATERIA LS
0 OTHES (Spec ify) - - - - - - --

BOX 8 (TO BE ACCOM PLISHE D BY THE SANITA RYS ECTION OF THE

OFFICE OF THE BUILDIN G OFFICIA L) To be shown
to the applican t.

REVIEWED:
T-
PROGRE SS FLOW
IN OUT
l
ACTION/ REMARKS PROCESSED BY

t~-
CHIEF, SANITARY SECTION
RECEIVING AND RECORDI NG
SANITARY -
OTHERS (Specify)
_l_

BOX 9 (TO BE ACCOMPLISHED BY THE SANITARY SECTIO

N OF THE OFFICE OF THE BUILDI NG OFFICIAL)
- 'I
ASSESSED FEES
AMOUNT DUE ASSESSED BY O .R. NUMBE f DATE PAID REVIEW ED BY:
SANITARY
OTHERS (Specify)

CHIEF. PROCESSING AND EVALUATION DIVISION

BOX10 ./

ACTIO N TAKEN:
PERMIT IS HEREBY ISSUED SUBJECT TO THE FOLLOW
I NG :

1. THAT THE DESIGNER IS AWARE THAT UNDER ARTICLL 1723

OF THf CIVIL CODE OF THE PHILIPPINES, HE/SHE IS RESPONS
COLLAPSE WITHIN FIFTEE N (15) YEARS FROM THE COMPLET IBLE FOR DAMAGES IF IT SHOULD
ION OF THE BUILDING/STRUCTURE, IF DUE TO DE FECT IN
DEFECTS IN THE GROUND. HE/SHE IS THEREFORE ENJOINED THE PLANS OR SPECIFICATIONS OR
TO CONDUCT PERIODIC INSPECTIONS OF THE BU ILDING/ST
CONDITIONS UNDER WHICH THE BUILDING/STRUCT URE WAS RUCTURE TO ENSURE THAT THE
DESIGNED ARE NOT BEING VIOLATED OR ABUSED.
2. THAT THE PROPOSED SANITARY WORKS SHALL BE IN ACCORDA
NCE WITH THE SANITARY PLANS FILED WITH THIS OFFICE
LATEST CODE ON SANITATION OFTHE PHILIP[PINES,TIIl CODE AND IN CONFORMITY W ITH THE
A ND ITS IRR.
3. THAT UPON COMPLETION OF THE SANITARY WORKS, THE
LICE NSED SUPERVISOR SHALL SUBMIT THE ENTRY TO THE
LOGBOOK DULY SIGNED AND SEALED TO
THE BUILDING OFFICIAL INCLUDING AS-BUILD PLANS liND
OTHER DOCUMENTS AND SHALL ALSO ACCOM PLISH THE
THAT THE SANITARY WORKS CONFORM TO THE PROVISIO CERTIFICATE OF COMPLETION STATING
N OF THE CODE ON SANITATI ON,THE CODE AND ITS IRR.
4. THAT TH IS PERMIT IS NULL AND VOID UNLESS ACCOMP liSHED
BY THE BUILDING PERMIT.

RECOM MENDIN G ISSUANC E OF SANITAR Y PERMIT :

- CHI EF,-SANITARY SECTION

(Signatu re Over Printed Na me)
Date - -- - ----

CHIEF-;-P-ROCESSING AND EVALUA TION D IVISION

(Signatu re Over Printed Name)

D a t e - - - - - - --

PERMIT ISSUED:

~i nunong ~anggusali
(Buildin g Official)
Date