Republic of the Philippines

Quezon City
DEPARTMENT OF THE BUILDING OFFICIAL
APPLICATION FOR MECHANICAL PERMIT

APPLICATION NO. DATE OF APPLICATION:

Reference No: REG-20210616-047199

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

OWNER/APPLICANT
ADORABLE, FELICIANO
FORM OF OWNERSHIP TELEPHONE NO.
INDIVIDUAL +63 917-520-0322
ADDRESS NO. STREET BARANGAY CITY/MUNICIPALITY ZIP CODE
109 MATAHIMIK ST., BRGY. TEACHER'S VILLAGE WEST, QUEZON CITY
LOCATION OF CONSTRUCTION: LOT NO: BLK NO: TCT NO: 114312812 TAX DEC. NO.: E-021-00910

STREET:: MATAHIMIK STREET, BARANGAY TEACHERS VILLAGE WEST 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

ADORABLE, FELICIANO CUSTODIO

(Signed and Sealed Over Printed Name)
PROFESSIONAL MECHANICAL ENGINEER
(Signed and Sealed Over Printed Name) Date

Date

ADDRESS ADDRESS

PRC NO. 2655 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

ADORABLE, FELICIANO FELICIANO C. ADORABLE JR.

(Signed Over Printed Name) (Signed 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:

ADORABLE, FELICIANO

APPLICANT: CTC NO. DATE ISSUED PLACE ISSUED

CTC NO. DATE ISSUED PLACE ISSUED

(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 their
free and voluntary act and deed.

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

Doc. No.

Page. No.

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