REPUBLIC OF THE PHILIPPINES )

QUEZON CITY ) S.S.

AFFIDAVIT OF CHANGE OF PERSON IN-CHARGE OF INSTALLATION

(For Issuance of Sanitary/Plumbing Certificate)

We, both of legal age, Filipino and after being sworn to in accordance with law, hereby
depose and say THAT:

1. I am the owner and/or developer of the ______________________________________________

____________________________________ (building/structure) located at
___________________________________________________________________, Quezon
City;
2. The installation of all sanitary/plumbing rough-ins, fixtures and private sewage disposal system of
the subject building/structure was to be initially undertaken by ____________________________
____________________, a Sanitary Engineer/Master Plumber, who was hired as the Person In-
Charge of the Installation, as indicated in the Sanitary/Plumbing Permit No __________________
issued on __________________ by the Department of Building Official, Quezon City;
3. The aforementioned Person In-charge of Installation was unable to start/complete the installation
of all sanitary/plumbing rough-ins, fixtures and private sewage disposal system of the project
because of the following reason/s with attachment of proof, to wit;(please check below);
1. death. 2. went or work abroad
3. physical incapacity due to 4. revocation or suspension of PRC
illness/accident. ID/Registration.
5. valid ground of termination by the 6. court order prohibiting the practice
owner/applicant. of profession.
7. Other/s: specify ___________________________________________________________

4. His/her unstarted/unfinished services were continued by ________________________________,

a Sanitary Engineer or Master Plumber, who until the completion of the project was the one who
acted as the Person In-Charge of Installation for all and or the remaining one who acted as the
Person In-Charge of Installation for all and or the remaining installation of sanitary/plumbing
rough-ins, fixtures and private sewage disposal system;

5. We hereby certify to the truthfulness and veracity of the above stated paragraphs , and we will
jointly assume any civil and/or criminal liability in case of failures and damages incurred to the
aforementioned building/structure, under its normal use or occupancy, within fifteen (15) years
from the date of Issuance of the Sanitary/Plumbing Certificate.

IN WITNESS WHEREOF, we hereunto set our hands this ____________________ day of

___________ at Quezon City.
CONFORME:

Affiant A f f i a n t (Sanitary Engineer/Master Plumber)

(Owner/Developer)
Residence Cert. No. ____________________
Issued on ____________________________
Issued at _____________________________
(In-Charge of Installation)
PRC No. _____________________________
PTR No. _____________________________
Issued on ____________________________
Issued at _____________________________
TIN __________________________________

SUBSCRIBED AND SWORN to before me this __________ day of _____________________ 20___

at ______________________, with the affiants exhibiting to me their foregoing respective Identification cards
above stated as proof of their personal Identities.

Doc. No. __________

Book No. _________
Page No. _________