Republic of the Philippines

Quezon City
DEPARTMENT OF THE BUILDING OFFICIAL
APPLICATION FOR MECHANICAL PERMIT

APPLICATION NO. DATE OF APPLICATION: 3/8/2021 7:46:04AM

BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE OWNER/APPLICANT AND BY THE DESIGN PROFESSIONAL

OWNER/APPLICANT LAST NAME FIRST NAME M.I.

LEE GARY L
FORM OF OWNERSHIP TELEPHONE NO.
COMPANY
ADDRESS NO. STREET BARANGAY CITY/MUNICIPALITY ZIP CODE

LOCATION OF CONSTRUCTION: LOT NO: 5 BLK NO:

3 TCT NO: TAX DEC. NO.:

LOT NO: BARANGAY IMMACULATE CONCEPCION QUEZON CITY

SCOPE OF WORK:
NEW CONSTRUCTION RENOVATION RAISING

ERECTION CONVERSION DEMOLITION

ADDITION REPAIR ACCESSORY BUILDING STRUC.

ALTERATION MOVING OTHERS (Specify)

BOX 2 BOX 3
DESIGN PROFESSIONAL, PLANS AND SPECIFICATIONS SUPERVISOR IN-CHARGE OF MECHANICAL WORKS

PROFESSIONAL MECHANICAL ENGINEER MECHANICAL ENGINEER

PROFESSIONAL MECHANICAL ENGINEER (Signed and Sealed Over Printed Name)

(Signed and Sealed Over Printed Name) Date

Date

ADDRESS ADDRESS

PRC NO. VALIDITY PRC NO. VALIDITY

PTR NO. DATE ISSUED PTR NO. DATE ISSUED

Issued at: TIN Issued at: TIN

BOX 4 BOX 5
APPLICANT: WITH CONSENT: LOT OWNER

(Signed and Sealed Over Printed Name) (Signed and Sealed Over Printed Name)

Date
Date

ADDRESS ADDRESS

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

BOX 6
REPUBLIC OF THE PHILIPPINES

CITY/MUNICIPALITY OF

BEFORE ME, at the City/Municiplity of on personally

append the following:

APPLICANT: CTC NO. DATE ISSUED PLACE ISSUED

LICENSED ARCHITECT OR CIVIL CTC NO. DATE ISSUED PLACE ISSUED

ENGINEER
(Full Time Inspector and Supervisor of Construction Work)

Whose signature appear hereinabove, known to me, to be the same peron who executed this standard prescribed form and acknowledged to that the same is
theirand voluntary act and deed.
free

WITNESS MY HAND AND SEAL on the date and place above written.

Doc. No.

Page. No.

Book No.
NOTARY PUBLIC (Until December ______________________ )
Series of.