NBC FORM NO.

E - 03

Republic of the Philippines

City/ Municipality of VILLANUEVA
Province of MISAMIS ORIENTAL
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 TELEPHONE NO

LOCATION OF CONSTRUCTION: LOT NO. ________ BLK NO. ____________ TCT NO. _____________________ TAX DEC. NO. ___________________
CABADBARAN
STREET______________________ BARANGAY ____________________________ CITY/ MUNICIPALITY 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
PROFESSIONAL ELECTRICAL ENGINEER
(Signed and Sealed Over Printed Name) PTR. No Date Issued
Date________________________ Issued at TIN
BOX 3
SUPERVISOR / IN-CHARGE OF ELECTRICAL WORKS
PROFESSIONAL ELECTRICAL ENGINEER REGISTERED ELECTRICAL ENGINEER REGISTERED MASTER ELECTRICIAN

Date______________
(Signed and Sealed Over Printed Name)

PRC. No Validity
PTR. No Date Issued
Issued at TIN
Address
BOX 4 (TO BE ACCOMPLISHED BY THE OWNER / APPLICANT)

OWNER / APPLICANT Address

C.T.C. No.

(Signature Over Printed Name) Date Issued

Date___________________ Place Issued