NBC FORM NO.

E - 03

Republic of the Philippines

City of Iloilo
Province of Iloilo

OFFICE OF THE BUILDING OFFICIAL

PERMIT FOR TEMPORARY SERVICE CONNECTION

CONTROL NO. PTSC NO.

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

OWNER/APPLICANT: LAST NAME FIRST NAME M.I. TIN

FOR CONSTRUCTION OWNED FORM OF OWNERSHIP USE OR CHARACTER OF OCCUPANCY

BY AN ENTERPRISE
ADDRESS: NO., STREET, BARANGAY, CITY/MUNICIPALITY ZIP CODE CONTACT NO./EMAIL ADDRESS
ILOILO 5000

LOCATION OF CONSTRUCTION: LOT NO. BLK NO. TCT NO. TAX DEC. NO.
ILOILO
STREET _______________________________________________ BARANGAY ____________________________________ CITY OF

PURPOSE:
FOR CONSTRUCTION FOR TESTING OTHERS (Specify)
SUMMARY OF ELECTRICAL LOADS / CAPACITIES APPLIED FOR
TOTAL CONNECTED LOAD TOTAL TRANSFORMER CAPACITY TOTAL GENERATOR/UPS CAPACITY

kVA kVA kVA

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

DESIGN PROFESSIONAL, PLANS AND SPECIFICATIONS

Address

PRC. No. Validity

____________________________________ PTR No. Date Issued

PROFESSIONAL ELECTRICAL ENGINEER
(Signed and Sealed Over Printed Name) Issued at TIN
Date ___________________________

BOX 3 (TO BE ACCOMPLISHED IN BY THE OWNER/APPLICANT

OWNER / APPLICANT Address

C.T.C. No.

Date Issued
____________________________________
(Signed and Sealed Over Printed Name) Place Issued
Date ___________________________
BOX 4 (TO BE ACCOMPLISHED BY THE PROCESSING &EVALUATION DIVISION)

FEE PAID: OFFICIAL RECEIPT NO.: _

DATE PAID: _ _ DATE ISSUED : _

BOX 5 (TO BE ACCOMPLISHED BY THE BUILDING OFFICIAL)

ACTION TAKEN:

Permit is hereby issued/granted to

with postal address at
to connect the electrical installation with the authorized load and purpose specified therewith pursuant to
pertinent provision of the latest Philippine Electrical Code, the National Building Code and its
Implementing Rules and Regulations for a period of ( ) days from
date after which period the service shall be disconnected unless
actually extended or renewed before the expiry date.

This permit shall be suspended or revoked any time before its expiration whenever alterations or
change in the wiring system have rendered it unsafe.

PERMIT ISSUED BY:

ENGR. MAVI J. GUSTILO

OIC, CITY BUILDING OFFICIAL
Date _________________