Republic of the Philippines

City/Municipality of _______
Province of ____________
OFFICE OF THE BUILDING OFFICIAL
ELECTRONICS PERMIT
A PPLICATION NO. ELPNO BUILDING PERMIT NO.

IIIIIIIIIII IIIIIIIII IIIIIIIII

BOX 1 (TO BE ACCOMPLISHED 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

I I
BY AN ENTERPRISE
ADDRESS: NO., STREET, BARANGAY, CITY/MUNICIPALITY ZIP CODE TELEPHONE NO
I

LOCATION OF CONSTRUCTION: LOT NO. BLK NO. TCT NO. TAX DEC. NO.
STREET BARANGAY CITY/ MUNICIPALITY OF
SCOPE OF WORK
0 NEW INSTALLATION 0 ANNUAL INSPECTION 0 OTHERS (Specify)
BOX 2 (TO BE ACCOMPLISHED BY THE DESIGN PROFESSIONAL)

NATURE OF INSTALLATION WORKS/EQUIPMENT SYSTEM:

0 TELECOMMUNICATION SYSTEM 0 ELECTRONICS FIRE ALARM SYSTEM 0 ELECTRONICS COMPUTERIZED PROCESS

CONTROLS AUTOMATION SYSTEM
0 BROADCASTING SYSTEM 0 SOUND COMMUNICATION SYSTEM □ CONTROL
BUILDING AUTOMATION MANAGEMENT AND
SYSTEM
0 TELEVISION SYSTEM 0 CENTRALIZED CLOCK SYSTEM 0 BUILDING WIRING UTILIZING COPPER CABLE,
0 INFORMATION TECHNOLOGY SYSTEM 0 SOUND SYSTEM FIBER OPTIC CABLE OR OTHER MEDIAL
ELECTRONICS SYSTEM
0 SECURITY AND ALARM SYSTEM 0 ELECTRONICS CONTROL AND CONVEYOR SYSTEM
0 ANY OTHER ELECTRONICS AND 1.T. SYSTEMS, EQUIPMENT, APPARATUS, DEVICE AND/OR COMPONENT (Specify) ___________

PREPARED BY----------------------------------

BOX3 BOX4
DESIGN PROFESSIONAL, PLANS AND SPECIFICATIONS SUPERVISOR/ IN-CHARGE OF ELECTRONICS WORKS

Date Date
PROFESSIONAL ELECTRONICS ENGINEER PROFESSIONAL ELECTRONICS ENGINEER
(Signed and Sealed Over Printed Name) (SiQned 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 al TIN
BOX5 BOX6
BUILDING OWNER WITH MY CONSENT: LOT OWNER

(Signature Over Printed Name) (Signature Over Printed Name)

Date Date
Address
CTC. No. I Date Issued
I
Plaoe Issued
Address
C.T.C. No.

I Date Issued
I
Plaoe Issued