Republic of the Philippines

Province of E. Samar
MUNICIPALITY OF BALANGKAYAN
‐o0o‐
OFFICE OF THE BUILDING OFFICIAL
___________________________________
APPLICATION FOR ELECTRICAL PERMIT

APPLICATION NO. DATE APPLICATION FILED

_______________________________________________
_________________________________
Date of proposed start of installation Expected Date of Completion

BOX 1(TOBE ACCOMPLISHED BY A PROFESSIONAL ENGINEER/ MASTER ELECTRICAL IN PRINT)

NAME OF OWNER/APPLICANT: LAST NAME: FIRST NAME: M.I. TIN

ADDRESS: NO. STREET BARANGAY CITY/MUNICIPALITY

TEL/FAX NO.

LOCATION OF INSTALLATION: NO. STREET CITY/MUNICIPALITY

Scope of Work: ( ) ADDITON OF ________________________ OTHERS (SPECIFY)

( ) NEW INSTALLATION ( ) REPAIR OF __________________________ ( )
_________________________
( ) ANNUAL INSPECTION ( ) REMAVAL OF ________________________ ( )
_________________________
TYPE OF OCCUPANCY OR USE:

( ) A. RESIDENTIAL ( ) E. BUSINESS & MERCHANTILE ( ) I. ASSEMBLY

OCCUPANT LOAD 1000 OR MORE
( ) F. INDUSTRIAL
( ) B. COMMERCIAL ( ) J. ACCESSORY

( ) C. INDUSTRIAL ( ) G. STORAGE & HAZARDOUS ( ) K. Other (Specify)

( ) D. INSTITUTIONAL ( ) H. ASSEMBLY OTHER THAN GROUP

NUMBER OF OUTLETS: NUMBER OF EQUIPMENT/WIRING DEVICES:

____________ SPO,
__________ LIGHT ___________ TOGGLE SWITCH __________ FA DETECTORS
COOKING UNIT

__________ ___________ BELLS/ BUZZERS __________OTHERS (See attached list)

CONVENIENCE/RECEPTACLE ____________ SPO, WATER
HEATER

__________ SPO/ AIRCON ___________ PISH BUTTOMS ____________

____________ SPO, WATER PUMP

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
SIGNATURE: DATE SIGNED: TIN
BOX 3(ELECTRICAL CONSTRUCTOR – 2‐ AMPERE MAIN AND ABOVE)
NAME: PCAB LIC. NO. ( SPECIFY ELECTRICAL )

DATE SIGNED: VALIDITY

BOX 4 (PERSON IN‐CHARGE OF INSTALLATION)

NAME SIGNATURE TIN CTC NO.____________________

DATE ISSUED________________
PLACE ISSUED_______________

RECEIVED BY: ______________________________________________________

ELECTRICAL PLANS & SPECIFICATIONS ( 5 SETS)
Signature Over Printed Name
( ) PROFESSIONAL ELECTRICAL ENGINEER ( ) REGISTERE ELECTRICAL ENGINEER ( ) REGISTERED MAIN ELECTRICIAN ( Not exceeding

600 volts & KVA)

NAME: PRC REG.NO. VALIDITY

ADDRESS: TEL/FAX NO.

PTR NO.: DATE ISSUED: PLACE ISSUED

SIGNATURE: DATE SIGNED: TIN

BOX 5 (OWNER/AUTHORIZED REPRESENTATIVE)

DATE RECEIVED: ____________________________________________________

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

Republic of the Philippines

Province of Samar
MUNICIPALITY OF CATBALOGAN
OFFICE OF THE BUILDING OFFICIAL

DISTRICT/CITY/MUNICIPALITY
AREA CODE ________________

PERMIT NO. APPLICATION NO.

DATE ISSUED: _______________

PAID UNDER O.R. NO. _________
AMOUNT: __________________
DATE: _____________________

ELECTRICAL PERMIT
(To be Accomplished by the Office Concerned)

PERMIT IS HEREBY GRANTED TO INSTALL THE ELECTRICAL WIRING, DEVICES AND EQUIPMENT ENUMERATED IN THE APPLICATION SUBJECT TO THE FOLLOWING

CONDITIONS:

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

2.
THAT DULY LICENSED ELECTRICAL PRACTITIONER BE INCHARGE OF THE INSTALLATIONS/CONSTRUCTION.

3.
THAT A CERTIFICATE OF COMPLITION DULY SIGNED BY THE ELECTRICAL PRACTITIONER INCHARGE OF THE INSTALLATION BE SUBMITTED NOT LATER

THAN SEVEN (7) DAYS AFTER COMPLETION OF THE INSTALLATION.

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

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

APPROVED:

_________________________________________ _________________________
ELECTRICAL ENGINEER OF THE BUILDING OFFICE DATE
(Signature Over Printed Name)

_________________
_________________
_______
 PRC REG. NO. & VALIDITY

PRC REG. NO. & VALIDITY

NOTED:

_________________________________________

_________________________

BUILDING OFFICIAL DATE

BUILDING OFFICIAL DATE
(Signature Over Printed Name)

BOX 1
NAME OF OWNER/APPLICATION: LAST NAME FIRST NAME MIDDLE NAME TIN

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

LOCATION OF INSTALLATION: NO. STREET BARANGAY CITY/ MUNICIPALITY

BOX 2
ASSESSED FEES
AMOUNT DUE ASSESSES O.R. NUMBER DATE PAID

REVIEWED

CHIEF, PROCESSING DIV./SEC.

BOX 3

Note 1: This Permit may be cancelled or revoked pursuant to Sections 305 and 306 of the National Building Code.
Note 2: Alterations on this form are not allowed