APPLICATION FOR LOCATIONAL CLERANCE/CERTIFICATE OF ZONING COMPLIANCE Annex A of

HSRC Memorandum Cir. No. 03 Series of 1996

OFFICE OF THE ZONING ADMINISTRATOR

_____________________________________________________________________________________________
1. Name of Applicant: Address

_____________________________________________________________________________________________
2. Name of Corporation Address

_____________________________________________________________________________________________
3. Name of Authorized Representative Address

_____________________________________________________________________________________________
4. Project Type 5. Project Nature
( ) New Development
( ) Improvement
( ) Others/Specify
_____________________________________________________________________________________________
6. Project Location (No./St./Brgy./City/Municipality, Province)

Lot area:
_____________________________________________________________________________________________
7. Project Area (in square meters) Building(s) Improvement

Lot area: Floor area:

_____________________________________________________________________________________________
8. Right Over Land 9. Project Tenure
( ) Owner ( ) Permanent
( ) Lessees ( ) Temporary (specify year)
( ) Others Specify
_____________________________________________________________________________________________
10. Existing Land Uses of Project Site ( ) Vacant/Idle
( ) Residential ( ) Industrial ( ) Agricultural Specify Crops
( ) Institutional ( ) Others Specify ___________________________
( ) Commercial ( ) Tenanted ( ) Non Tenanted
_____________________________________________________________________________________________
11. Project Cost/capitalization (In pesos, write in words and figures

Php
_____________________________________________________________________________________________
12. IS THE PROJECT APPLIED FOR THE SUBJECT OR WRITTEN NOTICE(S) FROM THIS OFFICE AND/OR
ITS DEPUTIZED ZONING ADMINISTRATOR TO THE EFFECT REQUIRING FOR PRESENTATION OF
LOCATIONAL CLEARANCE/CERTIFICATE OF ZONING COMPLIANCE (LZ/CZC) OR TO APPLY LC/CZC?
( ) Yes ( ) No if Yes Please answer the following

12.a Name of HLURB Officer or Zoning Administrator who issued the Notice(s)
12.b Date(s) of Notice
_____________________________________________________________________________________________
13. IS THE PROJECT APPLIED FOR THE SUBJECT SIMILAR APPLICATION WITH OTHER OFFICES OF
THE COMMISSION AND/OR DEPUTIZED ZONING ADMINISTRATOR? ( ) Yes ( ) No 13.a Other
13.b Date(s) Filed
13.c Action(s) taken by Office(s) mentioned in 16.a
_____________________________________________________________________________________________
14. PREFERRED MODE OF RELEASE OF DECISION
( ) Pick-up ( ) By mail, Address to:
( ) Applicant ( ) Authorized Representative
_____________________________________________________________________________________________
15. SIGNATURE OF APPLICANT 16. Signature of Authorized Representative

_____________________________________________________________________________________________
Republic of the Philippines )
______________________ )

SUBSCRIBED AND SWORN TO before me this _______ day of _____________________ in the

City/Municipality of ______________________, Province of ____________________ affiant exhibit to me his/her
Residence Cert No.___________________ issued at _____________________ on _____________________.

____________________________
NOTARY PUBLIC
 (DAR)

APPLICATION FOR ZONING CERTIFICATE

In connection with my application for conversion may I request Zoning Certification for
the following landholdings:

a. No. of Parcels :

b. Location of Property :

c. Total Area (has.) :

d. Proposed Use :

e. Description of Landholdings :

AREA APPLIED
REGISTERED OWNER LOT NO. TCT NO. AREA PER FOR
TCT CONVERSION

TOTAL ________________

Applicant/Owner
Printed Name : ___________________________
Signature : ___________________________
Address : ____________________________
ANNEX “B”

THE ZONING ADMINISTRATOR

MUNICIPALITY OF LUPAO
PROVINCE OF NUEVA ECIJA

APPLICATION FOR ZONING CERTIFICATION

_____________
Date

THE ZONING ADMINISTRATOR

Lupao, Nueva Ecija

Sir:

In accordance with Executive Order No. 648, as strengthened by LOI 729, EO 90 and EO
72, I am applying for Zoning Certification of property situated in ________________________,
(Barangay)
_______________________,___________________________ with OCT No/Nos. __________
(Municipality) (Province)
and with an area of _________________________________ square meters.

The undersigned attest that the documents submitted are in accordance with the pertinent
laws, decree, rules and regulations, standards and guidelines and that I assume full responsibility
from any non-compliance or violation thereof.

Attached hereto are:

1. Vicinity map indicating clearly and specifically the exact location of the proposed site
and the existing land uses and/or landmarks within a radius of at least 500 meters duly
signed by a geodetic/civil engineer or architect.
2. Lot plan duly signed by a licensed Geodetic Engineer.
3. Photocopy of the TCT, or any proof of ownership, or right over the property and/or
latest tax declaration; and
4. Filing Fee of _____________________________________.

Very truly yours,

________________________
Owner/Applicant
________________________
Address
________________________
Tel. No.
Republic of the Philippines )
_______________________) s.s.

SUBSCRIBED AND SWORN TO before me this _______ day of ___________________ in the

Municipality of __________________, Province of ___________________. Affiant exhibiting to
me his/her Community Certificate No. ________________________ issued at
__________________________ on _________________________.

__________________
Notary Public
Doc. No. ___________
Page No. ___________
Book No. ___________
Series of ____________
 Republic of the Philippines
Province of Nueva Ecija
MUNICIPALITY OF LUPAO

OFFICE OF THE ZONING ADMINISTRATOR

ZONING CERTIFICATION

____________
Date

This is to certify that the parcel/s of land situated in Barangay(s) Bagong Flores
Municipality of Lupao covering a total area of 7,091 sq meters specifically identified as follows.

Registered Owner Lot No(s) OCT/TCT No. Area Per Title Zoning
(Has.) Classification

Dominador S. Escritor Lot 3, Psd-03-016456 N-26835 7,091 sq m Agricultural

x-x-x-x-x-x-x-x-x-x-x-x-x x-x-x-x-x-x-x-x-x-x- x-x-x-x-x-x-x-x x-x-x-x-x-x-x-x x-x-x-x-x-x-x-x-x-

which is subject of application for Zoning Certification based on the duly certified zoning
map/vicinity map submitted by the applicant, is/are zoned for use(s) specified in the above table
per approved Comprehensive Land Use Plan/Zoning Ordinance of the city/municipality of Lupao.
Nueva Ecija dated 1-19-2000 ratified by the HLURB/Sangguniang Bayan/Sangguniang
Panlalawigan (SB/SP) through Board/SB/SP Resolution No. 206 s 2000 dated 24 July 2000 in
accordance with pertinent issuances.

Conditions:

[ ] this certification shall not be considered as a locational clearance/certificate of zoning

conformance or development permit.
[ ] This certification shall not be considered as a certification of the HLURB as to the
ownership by the applicant of the parcel of land subject of this certification.
[ ] Any misrepresentation or material false hood on the part of the applicant shall be
sufficient cause for cancellation of this certification.
[ ] Others:

ENGR. BERNARDO V. BASCOS

MPDC/Zoning Administrator