DPWH FORM NO. 96-001-E

REPUBLIC OF THE PHILIPPINES DEPARTMENT OF PUBLIC EORKS AND HIGHWAYS

OFFICE OF THE BUILDING OFFICIAL

CITY OF BACOOR DISTRICT CITY

AREA CODE 04119

APPLICATION NO. DATE APPLICATION FIELD:

APPLICATION FOR ELECTRICAL PERMIT (Accomplish in print and in duplicate)

_________________________ ___________________ Date of Proposed Start of Installation Expected Date of Completion

BOX 1 (TO BE ACCOMPLISHED BY A DULY QUALIFIED ELECTRICAL PRACTITIONER)

NAME OF OWNER/APPLICANT: LAST NAME FIRST NAME MIDDLE NAME TIN

ADDRESS NO. STREET BARANGAY CITY/.MUNICIPALITY TEL. /FAX NO.

LOCATION OF INSTALLATION NO. STREET BARANGAY CITY OF BACOOR

SCOPE OF WORK ADDITION OF ____________________ OTHERS (SPECIFY) NEW INSTALLATION REPAIR OF ____________________ _________________________ ANNUAL INSPECTION REMOVAL OF ____________________ ___________________________

TYPE OF OCCUPANCY OR USE A. RESIDENTIAL DWELLING E. BUSINESS & MERCHANTILE I. ASSEMBLY OCCUPANCY LOAD 1000 OR MORE B. RESIDENTIAL, HOTEL, APARTMENT F. INDUSTRIAL J. ACCESORY C. EDUCATION & RECREATION G. STORAGE K. OTHERS (SPECIFY) _________________ D. INSTITUTIONAL H. ASSEMBLY OTHER THAN GROUP 1

NUMBER OF OUTLETS _______ LIGHT _______ SPO. COOKING UNIT _______ CONVENIENCE/RECEPTABLE _______ SPO. WATER HEATER _______ SPO. AIRCON _______ SPO. WATER PUMP

NUMBER OF EQUIPMENT/WIRING DEVICES _______TOGGLE SWITCH _______ FA DETECTORS _______ BELLS/BUZZER _______ OTHERS (See Attached List) _______ PUSH BUTTONS ____________________

BOX 2 (PROFESSIONAL ELECTRICAL ENGINEER WHO SIGNED AND SEALED PLANS & SPECIFICATIONS)

NAME PRC REG. NO. VALIDITY

ADDRESS TEL. /FAX NO.

PTR NO. DATE ISSUED PLACE ISSUED

SIGANTURE DATE SIGNED TIN

BOX 3 (ELECTRICAL CONTRACTOR – 200 AMPERE MAIN AND ABOVE)

NAME PCABLIC. NO (SPECIALTY ELECTRICAL). VALIDITY

ADDRESS TEL. / FAX NO.

BOX 4 (PERSON-IN-CHARGE OF INSTALLATION)

PROFESSIONAL ELETRICAL ENGINEER REGISTERED ELECTRICAL ENGINEER REGISTERED MASTER ELECTRICIAN (NOT EXCEEDING 600 VOLTS & 500KVA)

NAME PRC REG. NO. VALIDITY

ADDRESS TEL./FAX NO.

PTR NO. DATE ISSUED PLACE ISSUED

SIGNATURE DATE SIGNED TIN

BOX 5 (OWNER/AUTHORIZED REPRESENTATIVE)

NAME SIGANTURE TIN CTC NO. ____________________ DATE ISSUED ____________________ PLACE ISSSUED ____________________

BOX 6 (TO BE RECEIVED BY RECEIVING/RECORDING SECTION)

ELECTRICAL PLANS & SPECIFICATIONS (5 SETS)

RECEIVED BY : _____________________________________________ SIGNATURE OVER PRINTED NAME DATE RECEIVED : _____________________________________________

DPWH FORM NO. 95-002-E

REPUBLIC OF THE PHILIPPINES DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS

OFFICE OF THE BUILDING OFFICIAL

CITY OF BACOOR DISTRICT CITY

AREA CODE 04119

PERMIT NO. APPLICATION NO.

DATE ISSUED _________________ DATE FILLED _________________ PAID UNDER O.R. NO. _________________ AMOUNT _________________ DATE _________________

ELECTRICAL PERMIT

BOX 1

NAME OF OWNER/APPLICANT LAST NAME FIRST NAME MIDDLE NAME TIN

ADDRESS NO. STREET BARANGAY CITY/MUNICIPALITY

LOCATION OF INSTALLATION NO. STREET BARANGAY CITY OF BACOOR

BOX 2

ASSESED FEES AMOUNT DUE ASSESED BY O.R. NO. DATE PAID

REVIEWED

_______________________________ CHIEF, PROCESSING DIV/SEC

BOX 3

PERMIT IS HEREBY GRANTED TO INSTALL THE ELECTRICAL WIRING, DEVICES AND EQUIPMENT ENUMERATED IN THE APPLICANT ION SUBJECT TO THE FOLLOWING CONDITIONS.

1. THAT THE PROPOSED INSTALLATIONS BE IN ACCORDANCE WITH THE APPROVED PLANS FILED WITH THIS OFFICE AND INCONFORMITY WITH THE PROVISIONS OF THE LATEST EDITION OF THE PHILIPPINE ELECTRICAL CODE.

2. THAT A DULY LICENSED ELECTRICAL PRACTITIONER BE INCHARGDE OF THE INSTALLATION / CONSTRUCTION.

3. THAT A CERIFICATE OF COMPLETION DULY SIGNED BY THE ELECTRICAL PRATIOTIONER INCHARGE OF THE INSTALLATION BESUBMITTED NOT LATER THAN A SEVEN (7) DAYS AFTER COMPLETION OF THE INSTALLATION.

4. THAT A CERTIFICATE OF FINAL ELECTRICAL INSPECTION BE SECURED PRIOR TO THE ACTUAL OCCUPANCY OF THE BUILDING

5. THIS PERMIT SHALL BE POSTED AT THE DOOR OR SITE OF WORK.

RECOMMENDING APPROVAL :

ENGR. RODERICK C. JAVINAL / ENGR. BERNANRDO MANALILI ENGINEER I I ENGINEER I

__________________________ PRC REG. NO.

NOTED BY: APPROVED BY:

ENGR. FELICITO R. MEJIA HON. LANI MERCADO-REVILLACITY MAYOR BUILDING OFFICIAL

NOTE 1: This permit may be cancelled or revoked pursuant to Section 305 & 306 of the National Building Code NOTE 2: Alterations on this form are not allowed

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