Republic of the Philippines

Province of Pampanga
CITY OF SAN FERNANDO

UNIFIED APPLICATION FORM FOR CERTIFICATE OF OCCUPANCY/USE

(FM-CSFP-QMS-37; Revision No. 00; 02/08/2021)

FULL PARTIAL

SIMPLE COMPLEX HIGHLY TECHNICAL

Building Permit No :
Date Issued :
FSEC No. :
Date Issued :
(Date)

Name of Owner/Permittee:
(Last Name) (Given Name) (Middle Initial)

Address of Owner/Permittee:
Contact No.: ZIP Code:
Name of Project:
Location of Project:

Use/Character of Occupancy:
No. of Storey's:
No. of Units:
Total Floor Area(Sq. M.):
Date of Completion:

Attested by: Submitted by:

FULL-TIME INSPECTOR OR SUPERVISOR OF CONTRUCTION

ARCHITECT or CIVIL ENGINEER OWNER / PERMITTEE

(Signature and Sealed Over Printed Name) (Signature Over Printed Name)
Date:

PRC No. Validity Community Tax Cert. No.

PTR No. Date Issued Date Issued:
Issued at TIN Place Issued
CTC No. Date Issued Issued at

REPUBLIC OF THE PHILIPPINES ) s.s

CITY/MUNICIPALITY OF _________________)

BEFORE ME, at the City/Municipality of ______________________, on __________________ personally

appeared the following:

______________________________ _________ ____________ ______________________

APPLICANT CTC NO. DATE ISSUED PLACE ISSUED
______________________________ _________ ____________ ______________________
LICENSED ARCHITECT OR CIVIL ENGINEER CTC NO. DATE ISSUED PLACE ISSUED
(Full-Time Inspector and Supervisor of Construction Works)

whose signature appear hereinabove, know to me to be the same person who executed this standard prescribed
form and acknowledged to me that the same is their free and coluntary act and deed.

WITNESS MY HAND AND SEAL on the date and place above written.
Doc. No
Page No.
Book No.
Series of
NOTARY PUBLIC (Until December _________ )

NOTE: PROVIDE LOCATION SKETCH AT THE BACK

Location Sketch: