NBC FORM NO.

A-06
Republic of the Philippines
DEPARTMENT OF PUBLIC WORKS & HIGHWAYS
OFFICE OF THE BUILDING OFFICIAL

MUNICIPALITY

SANITARY PERMIT
APPLICATION NO. SP NO. PERMIT NO.

DATE OF APPLICATION DATE ISSUED

BOX 1 (TO BE ACCOMPLISHED BY SANITARY ENGINEER/MASTER PLUMBER, IN PRINT)

NAME OF OWNER/APPLICANT LAST NAME, FIRST NAME, M.I. TAX ACCT. NO.

ADDRESS No., Street, Barangay, City/Municipality TELEPHONE NO.

Location of Installation No., Street, Barangay, City/Municipality

SCOPE OF WORK
NEW CONSTRUCTION RENOVATION RISING
ERECTION CONVERSION DEMOLITION
ADDITION REPAIR ACCESSORY BUILDING/STRUCTURE
ALTERATION MOVING OTHERS (specify)

USE OR TYPE OF OCCUPANCY

Residential Agricultural
Commercial Parks, Plazas, Monuments
Industrial Recreational
Institutional Others (Specify)
BOX 2 (TO BE ACCOMPLISH BY THE DESIGNING PROFESSIONAL)
INSTALLATION AND OPERATION

WATER SUPPLY SYSTEM OF DISPOSAL:

SHALLOW WELL WASTE WATER TREATMENT PLANT SURFACE DRAINAGE
DEEP WELL AND PUMP SET IMHOFF TANK STREET CANAL
CITY/MUNICIPAL WATER SYSTEM SANITARY SEWER CONNECTION WATER COURSE
OTHERS (specify) SUB-SURFACE AND FILTER OTHER (specify)

PREPARED BY :

BOX 3 BOX 4
DESIGN PROFESSIONAL, PLANS AND SPECIFICATIONS SUPERVISOR/IN-CHARGE OF SANITARY WORKS

SANITARY ENGINEER Date SANITARY ENGINEER Date

(signed and sealed over printed name) (signed and sealed over printed name)
Address Address
PRC NO. VALIDITY PRC NO. VALIDITY
PTR NO. DATE ISSUED PTR NO. DATE ISSUED
ISSUED AT TIN ISSUED AT TIN

BOX 5 BOX 6
BUILDING OWNER WITH MY CONSENT : LOT OWNER

(SIGNATURE OVER PRINTED NAME) (SIGNATURE OVER PRINTED NAME)

Address Address
CTC No. Date Issued Place Issued CTC No. Date Issued Place Issued
 BOX 7 (TO BE ACCOMPLISHED BY THE RECEIVING & RECORDING SECTION )
RECEIVED BY: DATE:
THREE (3) SETS OF SANITARY DOCUMENTS

Sanitary Plans & Specifications Cost Estimates

Bill of Materials Others (Specify)

BOX 8 (TO BE ACCOMPLISHED BY THE DIVISION / SECTION CONCERNED)

ASSESSED FEES
AMOUNT DUE ASSESSED BY O.R. NUMBER DATE PAID

BOX 9 (TO BE ACCOMPLISHED BY THE DIVISION / SECTION CONCERNED)

PROGRESS FLOW
IN OUT
NOTE ACTION/REMARKS PROCESSED BY
TIME DATE TIME DATE
Chief, Processing Division/Section
Receiving and Recording
Geodetic (Line and Grade)
Sanitary
BOX 10

ACTION TAKEN

PERMIT IS HEREBY ISSUED SUBJECT TO THE FOLLOWING ;

1 That the proposed sanitary works shall be in accordance with the sanitary plans filed
with this office and in conformity with the latest Code of Sanitation of the Philippines, the
National Building Code and its IRR.

2 That prior to any commencement of sanitary works, a duly accomplished prescribed

Notice of Construction" shall be submitted to the Office of the Building Official.

3 That upon completion of the sanitary works the licensed supervisor/in-charge shall
submit the entry to the logbook duly signed and sealed to the Building Official including
as-built plans and other documents and shall also accomplish the Certificate of Completion
stating that the sanitary works conform to the provision of the Code on Sanitation, the
National Building Code and its IRR

4 That this permit is null and void unless accompanied by the building permit

PERMIT ISSUED BY :

ARCH. KHASHAYAR L. TOGHYANI

Officer-In-Charge

THIS PERMIT MAY BE CANCELLED OR REVOKED PERSUANT TO SECTION. 305 & 306 OF THE "NATIONAL BUILDING CODE".
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