DPWTC FORM NO.

77-001- E
Republic of the Philippines
PROVINCE OF ZAMBOANGA DEL NORTE
Municipality of Katipunan
OFFICE OF THE BUILDING OFFICIAL
APPLICATION NO. PERMIT NO.
AREA CODE _______

APPLICATION OF
_________________________ ELECTRIC PERMIT ____________________
DATE OF APPLICATION DATE ISSUED

BOX 1 (TO BE ACCOMPLISHED BY PROFESSIONAL ELECTRICAL/MASTER ELECTRICIAN, IN PRINT)

NAME OF OWNER/APPLICANT LAST NAME FIRST NAME M.I TAX ACCT. NO.

ADDRESS NO., STREET, BARANGAY, CITY,/MUNICIPALITY TELEPHONENO.

LOCATION OF INSTALLATION NO., STREET, BARANGAY, CITY,/MUNICIPALITY

SCOPE OF WORK
NEW INSTALLATION ADDITION OF __________ OTHERS(SPECIFY)

ANNUAL INSPECTION REPAIR OF _____________ ____________ OF ____________

REMOVAL OF ___________ ____________ OF ____________

USE OR TYPE OF OCCUPANCY

RESIDENTIAL _______________ AGRICULTURAL __________________________

COMMERCIAL _________________ STREET FURNITURE, LANDSCAPING _________________

INDUSTRIAL ___________________ SIGNBOARDS ____________________________

INSTITUTIONAL ________________ OTHERS (SPECIFY) _______________________

DATE OF PROPOSED ESTIMATED COST OF

START OF CONSTUCTION ________________ ELECTRICAL INSTALLATION ________________

EXPECTED DATE PREPARED BY: _______________________

OF COMPLETION: ___________________

BOX 2 (TO BE ACCOMPLISHED BY RECEIVING & RECORDING SECTION)

ELECTRICAL DOCUMENTS FIVE (5) SETS EACH

ELECTRICAL PLAN & SPECIFICATIONS BILL OF MATERIALS

COST ESTIMATES OTHERS (SPECIFY) _________________

WE HEREBY AFFIX OUR HANDS SIGNIFYING OUR CONFORMITY TO THE INFORMATION HEREIN ABOVE SET FORTH

BOX 3 (PERSON WHO SIGNED AND SEALED PLANS & SPECIFICATION) BOX (PESON IN-CHARGE OF THE INSTALLATIONS)
ELECTRICAL ENGINEER/ PRC REG. NO ELECTRICAL ENGINEER/ PC REG. NO

PRINT NAME PRINT NAME

ADDRESS ADDRESS

P.T.R NO DATE ISSUED PLACE ISSUED P.T.R NO. DATE ISSUED PLACED ISSUED

SIGNATURE TAN SIGNATURE TAN

BOX 4
SIGNATURE (OWNER)
TAN RES. CERT. NO. DATE ISSUED PLACE ISSUED
BOX 5 (TO BE ACCOMPLISHED BY PROFESSIONAL ELECTRICAL ENGINEER/ELECTRICIAN, IN PRINT)
NAME OF OWNER/APPLICANT LAST NAME FIRST NAME M.I TAX ACCT. NO.

ADDRESS NO., STREET, BARANGAY, CITY/MUNICIPAL TEL NO.

LOCATION OF INSTALLATION NO., STREET, BARANGAY, CITY/MUNICIPAL

BOX 6

PROGRESS FLOW
NOTED IN OUT ACTION TAKEN PROCESSED BY

CHIEF, PROCESSING TIME DATE TIM DATE

DIVISION/SECTION E

RECEINVING AND RECORDING

ELECTRICAL
BOX 7 (TO BE ACCOMPLISHED BY THE BUILDING OFFICIALS)

ASSESSED FEES

AMOUNT DUE ASSESED BY O.R. NUMBER DATE PAID

REVIEWED BY

CHIEF, PROCESSING
DIV/SECTION
BOX 8 (TO BE ACCOMPLISHED BY THE BUILDING CONCERNED)

ACTION TAKEN:
PERMIT IS HEREBY GRANTED TO INSTALL THE ELECTRICAL
WIRING AND EQUIPMENT ENUMERATED HEREIN SUBJECT TO THE
FOLLOWING CONDITIONS.

1. THAT THE PROPOSED INTSALLATION SHALL BE IN ACCORDANCE

WITH APPROVED PLANS FILED WITH THIS OFFICE AND IN CONFIRMITY
THE NATIONAL BUILDING OFFICE.
2. THAT A DULY LICENSED ELECTRICAL ENGINEER/MASTER ELECTRICIAN
BE ENGAGED TO UNDERTAKE THIS INSTALLATION/CONSTRUCTION.
3. THAT A CERTIFICATE OF COMPLETION IS DULY SIGNED BY AN ELECTRICAL JUROLINE PAUL A. LAPUT
ENGINEER/MASTER ELECTRICIAN IN CHARGE OF INSTALLATION SHALL BE BUILDING OFFICIAL
SUBMITTED NOT LATER THAT SEVEN ( 7 ) DAYS AFTER COMP=LETION OF THE
INTALLATION. __________________
4. THAT A CERTIFIED OF FINAL INSPECTION AND A CERTIFICATE OF OCCUPANCY DATE
BE SECURED PRIOR TO THE ACTUAL OCCUPANCY OF THE BUILDING.

NOTE:
THIS PERMIT MAY BE CANCELLED OR REVOKED PURSUANT TO SECTION 305 AND 306 OF THE NATIONAL BUILDING CODE