Republic of the Philippines

MUNICIPALITY OF ALCALA
PROVINCE OF PANGASINAN

Office of the Building Official

ELECTRICAL PERMIT
APPLICATION NO. ELECTRICAL PERMIT NO.
1 0 - 1 9 - 3 2 2 1 0 - 1 9 - 0 3 2 2
OCTOBER 10, 2019
Date of Application Date Issued

BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE OWNER/APPLICANT)

OWNER/APPLICA
NT LAST NAME FIRST NAME M.I. TIN

FOR CONSTRUCTION OWNED BY AN FORM OF OWNERSHIP USE OR TYPE OF OCCUPANCY

ENTERPRISE
ADDRESS NO STREE BARANGAY CITY/MUNICIPALITY ZIP TELEPHONE
. T CODE NO.
BARANGAY ANULID, ALCALA, PANGASINAN 2425
LOCATION OF CONSTRUCTION
NO.
STREET BARANGAY CITY/MUNICIPALITY
BARANGAY ANULID, ALCALA, PANGASINAN
X
ANNUAL INSPECTION SEPARATION OF SERVICE ENTRANCE OTHERS (Specify) __________________
TEMPORARY UPGRADING OF SERVICE ENTRANCE _________________________________

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

SUMMARY OF ELECTRICAL LOADS/ CAPACITIES APPLIED FOR

TOTAL CONNECTED LOAD TOTAL TRANSFORMER CAPACITY TOTAL GENERATOR/ UPS CAPACITY
_________________ KVA _________________ KVA _________________ KVA

PRC. NO. 3323 VALIDITY : OCTOBER 23, 2021

PTR. NO. 2574688 DATE ISSUED : JAN. 03, 2019

ROGELIO Q. DUQUE
PROFESSIONAL ELECTRICAL ENGINEER
(Signed and Sealed Over Printed Name) Issued at : San Carlos City, Pang. TIN : 113-892-295
DATE ________________________
ADDRESS

BOX 3 (TO BE ACCOMPLISHED BY SUPERVISOR/ IN-CHARGE OF ELECTRICAL WORKS)

PROFESSIONAL ELECTRICAL REGISTERED ELECTRICAL REGISTERED MASTER

ENGINEER ENGINEER ELECTRICIAN

ROGELIO Q. DUQUE ______________________________________ ______________________________________

(Signed and Sealed Over Printed Name)
DATE ________________________
PRC. NO. 3323
PTR. NO. 2574688
Issued at : SAN CARLOS CITY, PANGASINAN
ADDRESS : SAN CARLOS CITY, PANGASINAN
(Signed and Sealed Over Printed Name) (Signed and Sealed Over Printed Name)
DATE ________________________ DATE ________________________
VALIDITY : OCTOBER 23, 2021
Date Issued : JANUARY 03, 2019
TIN : 113-892-295

BOX 4 (TO BE ACCOMPLISHED BY)

BUILDING OWNER: WITH MY CONSENT: LOT OWNER

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

ADDRESS ADDRESS

CTC NO. DATE ISSUED PLACE ISSUED CTC NO. DATE ISSUED PLACE ISSUED