REPUBLIC OF THE PHILIPPINES )

QUEZON CITY ) S.S.

AFFIDAVIT OF CHANGE OF PERSON IN-CHARGE OF INSTALLATION

(For Issuance of Certificate of Electrical Inspection)
That I, of legal age, Filipino and after being sworn to in accordance with law, hereby depose and
say:
That, I am the owner and/or developer of the _Newly renovated Mesa Restaurant ____________
__Located at Ayala Mall Trinoma, North Ave. cor. EDSA, Brgy. Bagong Pag-Asa, Quezon City;
That, the installation of electrical fixtures and wirings of the subject building/structure was to be
initially undertaken by _Danilo S. Petallar_______, a Registered Master Electrician (RME), Registered
Electrical Engineer (REE), Professional Electrical Engineer(PEE), who was hired as the Person Incharge of
the Installation, as indicated in the Electrical Wiring Permit No. _IEP230600657_, issued on
_JUN. 23, 2023__ by the Department of Building Official, Quezon CIty;
That, the aforementioned Person In-Charge of Installation was unable to start/complete the
installation of all electrical fixtures and wirings of the project because of any of the following reason/s with

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 6. court order prohibiting the
the owner/applicant. practice of profession.
7. Other/s: specify __Absent Without Offiical Leave_________________________________

That, his/her unstarted/unfinished services were continued by ______________________,

RME, REE, PEE, who until the completion of the project was the one who acted as the Person In-Charge
Installation for all and or the remaining installation of electrical fixtures and wirings;

That, we hereby certify to the truthfullness 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 occupancy, within fifteen (15) years from the date of
issuance of the Certificate of Electrical Inspection or CEI;

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

_________________ at Quezon City.

LYSANDER P. RAGODON
Affiant A f f i a n t (RME. REE, PEE)
(Owner/Developer) (Person In-Charge of Installation)

Residence Cert. No.__________________ PRC No. _____________________________

Issued on __________________________ PTR No. _________________________
Issued at ___________________________ Issued on ________________________
Issued at ______________________________

SUBSCRIBED AND SWORN to before me this _____________ day of ____________________,

20___ at ______________________________, with the affiantss exhibiting to me their respective
identification cards above stated as proof their personal identities.
Doc. No. _____________
Book No. ____________
Page No. _____________
Series No. ____________ Notary Public