NBC FORM NO.

A- 05

Republic of the Philippines

City/Municipality of ________________
Province of _________________________

OFFICE OF THE BUILDING OFFICIAL

SANITARY PERMIT
APPLICATION NO. SP NO BUILDING PERMIT NO.

OWNER/APPLICANT
BOX 1 (TO BE ACCOMPLISHED LAST NAMEBY THE OWNER/APPLICANT)
IN PRINT 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. ____________________
STREET___________________ BARANGAY _________________________________________ CITY/ MUNICIPALITY OF ___________________________________________

SCOPE OF WORK
NEW CONSTRUCTION RENOVATION ________________________ RAISING________________________________________
ERECTION CONVERSION ________________________ DEMOLITION ____________________________________
ADDITION REPAIR _____________________________ ACCESSORY BUILDING/STRUCTURE________________
ALTERATION MOVING _____________________________ OTHERS (Specify)_________________________________

BOX 2 (TO BE ACCOMPLISHED BY THE DESIGN PROFESSIONAL)

INSTALLATION AND OPERATION OF:

WATER SUPPLY: SYSTEM OF DISPOSAL:

SHALLOW WELL WASTE WATER TREATMENT PLANT SURFACE DRAINAGE

DEEP WELL & PUMP SET IMHOFF TANK STREET CANAL

CITY/MUNICIPAL WATER SYSTEM SANITARY SEWER CONNECTION WATER COURSE

OTHERS (Specify) ______________ SUB-SURFACE SAND FILTER OTHERS (Specify) ________________

PREPARED BY: ______________________________________________________________________________________________________________________________

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

Date_____________ Date_____________
SANITARY ENGINEER SANITARY ENGINEER
(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)

Date_________________ Date_________________
Address Address
C.T.C. No. Date Issued Place Issued C.T.C. No. Date Issued Place Issued

NOTE: THIS PERMIT MAY BE CANCELLED OR REVOKED PURSUANT TO SECTIONS 305 AND 306 OF THE “NATIONAL BUILDING CODE”.