REPUBLIC OF THE PHILIPPINES APPENDIX B

OFFICE OF THE CITY/MUNICIPAL MAYOR DO NOT FILL UP (NSO USE

ONLY)
MANILA
CITY/MUNICIPALITY
APPLICATION PERMIT NO.
NO. 6423423
12345 BUILDING PERMIT
JAN 10 2021 JAN 10 2021
DATE OF APPLICATION DATE ISSUED
ORIGINAL RENEWAL
BOX 1 (TO BE ACCOMPLISHED BY DESIGNING ARCHITECT/CIVIL ENGINEER IN PRINT
OWNER LAST NAME FIRST NAME M.I TAX ACCT. NO.

FOR CONSTRUCTION OWNED FORM OF OWNERSHIP MAIN ECONOMIC ACTIVITY/KIND OF BUSINESS

BY AN ENTERPRISE
ADDRESS TEL NO.
2000 Legarda Street Sampaloc, Manila 667 5887
LOCATION OF CONSTRUCTION
1000 G. Tuazon Street Sampaloc, Manila
SCOPE OF WORK: 1 NEW CONSTRUCTION OTHERS (SPECIFY)
2 ADDITION OF 6 OF
3 REPAIR OF 7 OF
4 RENOVATION OF
5 DEMOLITION OF NUMBER OF UNITS
USE OR TYPE OF OCCUPANCY
RESIDENTIAL  INDUSTRIAL
11 SINGLE  31 FACTORY/PLANT
12 DUPLEX 32 REPAIR SHOP, MACHINE SHOP
13 ROWHOUSE/ACCESSORIA 33 REFINERY
10 OTHERS (SPECIFY) 34 PRINTING PRESS
COMMERCIAL 35 WAREHOUSE
21 BANK 36 OTHERS (SPECIFY)
22 STORE INSTITUTIONAL
23 HOTEL/MOTEL, ETC. 41 SCHOOL
24 OFFICE CONDOMINIUM/BUSINESS,OFFICE BUILDING 42 CHURCH AND OTHER RELIGIOUS STRUCTURES
25 RESTAURANT, ETC. 43 HOSPITAL OR SIMILAR STRUCTURES
26 SHOP (e.g. DRESS SHOP, TAILORING SHOP, BARBER SHOP, ETC.) 44 WELFARE AND CHARITABLE STRUCTURES
27 GASOLINE STATION 45 THEATER, AUDITORIUM, GYMNASIUM, COURT
28 MARKET 46 OTHERS (SPECIFY)
29 DORMITORY OR OTHER LODGING HOUSE AGRICULTURAL
30 OTHERS (SPECIFY) 51 BARN(S) POULTRY HOUSE(S), ETC.
OTHER TYPE OF OCCUPANCY 52 GRAIN MILL
60 SPECIFY 53 OTHERS (SPECIFY)
STREET FURNITURE, LANDSCAPING & SIGNBOARDS
71 PARKS, PLAZAS, MONUMENTS, POOLS, PLANT BOXES, ETC.
72 SIDEWALKS, PROMENADES, TERRACES, LAMPOSTS, ELECTRIC POLES, TELEPHONE POLES, ETC.
73 OUTDOOR ADS, SIGNBOARDS, ETC.
74 FENCE ENCLOSURE
BOX 2 (TO BE ACCOMPLISHED BY THE RECEIVING & RECORDING SECTION
BUILDING DOCUMENTS (FIVE SETS EACH)
SITE DEVELOPMENT AND LOCATION PLAN MECHANICAL PLANS & SPECIFICATIONS
ARCHITECTURAL PLAN & SPECIFICATIONS LOGBOOK (1 COPY)
STRUCTURAL DESIGN & COMPUTATIONS OTHERS (SPECIFY)
SANITARY/PLUMBING PLANS & SPECIFICATIONS
ELECTRICAL PLANS & SPECIFICATIONS
BOX 3 (TO BE ACCOMPLISHED BY THE BUILDING OFFICIAL)
ACTION TAKEN
PERMIT IS HEREBY GRANTED SUBJECT TO THE FOLLOWING CONDITIONS:
1. THAT THE PROPOSED CONSTRUCTION/ADDITION/REPAIR/RENO-
VATION/DEMOLITION/INSTALLATION ETC. SHALL BE IN CONFORMITY WITH
THE NATIONAL BUILDING CODE (P.D. 1096) AND ITS CORRESPONDING
IMPLEMENTING RULES AND REGULATIONS.
2. THAT A DULY LICENSED ARCHITECT/CIVIL ENGINEER HAS BEEN ENGAGED
TO PREPARE PLANS AND SPECIFICATIONS AND TO UNDERTAKE THE
SUPERVISION/INSPECTION OF THE CONSTRUCTION OF THE PROJECT.
3. THAT A CERTIFICATE OF COMPLETION DULY SIGNED AND SEALED BY THE
DESIGNING ARCHITECT/ENGINEER AND THE ARCHITECT/ENGINEER IN-
CHARGE OF CONSTRUCTION SHALL BE SUBMITTED NOT LATER THAN
SEVEN (7) DAYS AFTER COMPLETION OF THE CONSTRUCTION OF THE
PROJECT.
4. THAT A "CERTIFICATE OF OCCUPANCY" SHALL BE SECURED PRIOR TO
ACTUAL OCCUPANCY OF THE BUILDING.
NOTE:
THIS PERMIT MAY BE CANCELLED OR REVOKED PURSUANT TO SECTIONS 305 & 306 OF THE "NATIONAL BUILDING CODE".
To be accomplished in five copies, one each for: applicant(original), Assessor, National Statistics Office, Building Official, Fire Department.
 BOX 3A (TO BE ACCOMPLISHED BY DESIGNING ARCHITECT/CIVIL ENGINEER IN PRINT)
TOTAL ESTIMATED COST COST OF NUMBER OF STOREYS 2 DO NOT FILL (NSO USE ONLY)
EQUIPMENT
BUILDING
INSTALLED TOTAL FLOOR AREA
ELECTRICAL
P PROPOSED DATE
MECHANICAL OF CONSTRUCTION MARCH 16 2021
P
PLUMBING EXPECTED DATE
P OF COMPLETION SEPT. 16 2021
OTHERS

TOTAL COST MATERIAL OF CONST.

(WOOD,CONC.,STEEL,MIXED)
BOX 4 (TO BE ACCOMPLISHED BY THE DIVISION/SECTION CONCERNED)
ASSESSED FEES
AMOUNT DUE ASSESSED BY O.R. DATE PAID
NUMBER
LAND USE/ZONING
LINE and GRADE
BUILDING
PLUMBING
ELECTRICAL
MECHANICAL
OTHERS REVIEWED:
TOTAL CHIEF PROCESSING DIVISION/SECTION
BOX 5 (TO BE ACCOMPLISHED BY THE DIVISION/SECTION CONCERNED)
PROGRESS FLOW
NOTED: IN OUT ACTION PROCESSED
CHIEF, PROCESSING DIVISION/SECTION TIME DATE TIME DATE REMARKS BY
7:30 AM 01/11/2021 8:30 AM 01/11/2021
RECEIVING and RECORDING
8:30 AM 01/11/2021 9:30 AM 01/11/2021
LAND USE and ZONING
9:30 AM 01/11/2021 10:30 AM 01/11/2021
GEODETIC (LINE and GRADE)
10:30 AM 01/11/2021 11:30 AM 01/11/2021
ARCHITECTURAL
11:30 AM 02/11/2021 12:30 AM 02/11/2021
STRUCTURAL
1:30 PM 02/11/2021 2:30 PM 02/11/2021
SANITARY/PLUMBING
2:30 PM 02/11/2021 3:30 PM 02/11/2021
ELECTRICAL
3:30 PM 02/11/2021 4:30 PM 02/11/2021
MECHANICAL
WE HEREBY AFFIX OUR HANDS SIGNIFYING OUR CONFORMITY TO THE INFORMATION HEREIN ABOVE SETFORTH.
BOX 6 BOX 8
ARCHITECT/CIVIL ENGINEER PRC REG. NO. SIGNATURE
SIGNED AND SEALED PLANS & SPECIFICATIONS
PRINT NAME: ALYSSA MONIQUE CAYA

ADDRESS: 2400 Legarda St. Sampaloc, Manila APPLICANT

COMMUNITY TAX CERT DATE ISSUED PLACE ISSUED
PTR NO. 102153
JAN 10 2021 MANILA
SIGNATURE:

WITH MY CONSENT
BOX 7 BOX 9 (TO BE ACCOMPLISHED BY LOT OWNER)
ARCHITECT/CIVIL
FORM NO. A - ENGINEER PRC REG. NO. TCT/OCT NO.
03 SIGNED AND SEALED PLANS & SPECIFICATIONS REPUBLIC OF THE PHILIPPINES
PRINT NAME: ALYSSA MONIQUE CAYA PRINT NAME OF LOT OWNER: ALLAN CASIDSID
City/Municipality of Manila
ADDRES: 2400 Legarda St. Sampaloc, Manila Province of Metro Manila ADDRESS: 123 Roxas St. Sampaloc, Manila
PTR NO. DATE ISSUED OFFICE OF THE BUILDING
PLACE ISSUED COMMUNITYOFFICIAL
TAX CERT.

SIGNATURE: MANILA SIGNATURE:

ELECTRICAL PERMIT
APPLICATION NO.
EP NO. BUILDING PERMIT NO.
1 2 3 4 5 6 7 8 9 0 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2

BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE OWNER/APPLICANT)

OWNER/APPLICANT LAST NAME 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.

SCOPE OF WORK
NEW INSTALLATION RECONNECTION OF SERVICE ENTRANCE RELOCATION OF SERVICE ENTRANCE
ANNUAL INSPECTION SEPARATION OF SERVICE ENTRANCE OTHERS (Specify)
 TEMPORARY UPGRADING OF SERVICE ENTRANCE

SUMMARY OF ELECTRICAL LOAD/CAPACITIES APPLIED FOR

TOTAL CONNECTED LOAD TOTAL TRANSFORMER CAPACITY TOTAL GENERATOR/UPS CAPACITY

kVA kVA kVA

BOX 2 (TO BE ACCOMPLISHED IN PRINT BY THE DESIGN PROFESSIONAL)

DESIGN PROFESSIONAL, PLANS AND SPECIFICATIONS
Address

Date PRC. No. Validity

PROFESSIONAL ELECTRICAL ENGINEER PTR. No. Date Issued

(Signed and Sealed Over Printed Name)
Issued at TIN

BOX 3
SUPERVISOR / IN-CHARGE OF ELECTRICAL WORKS
PROFESSIONAL ELECTRICAL ENGINEER REGISTERED ENGINEER REGISTERED MASTER ELECTRICIAN

KENNETH ELARDE Date January 10, 2021

(Signed and Sealed Over Printed Name)

PRC. No. 12321123 Validity: 2050

PTR. No. 123123123 Date Issued: January 10, 2021
Issued No. 1234121 TIN: 22332123
Address: 234 Rizal St. Quiapo Manila
BOX 4

BUILDING OWNER WITH MY CONSENT: LOT OWNER

Date Date
(Signature Over Printed Name) (Signature Over Printed Name)

Address Address
C.T.C. No. Date Issued Place Issued C.T.C. No. Date Place Issued
Issued
TO BE ACCOMPLISHED BY THE PROCESSING & EVALUATION DIVISION

BOX 6
RECEIVED BY RECEIVED BY

FIVE (5) SETS OF ELECTRICAL DOCUMENTS

EXPECTED DATE OF COMPLETION/INSTALLATION/CONSTRUCTION
ELECTRICAL PLANS AND SPECIFICATIONS
SPECIAL FIXTURES AND EQUIPMENT

PROPOSED STARTING DATE OF INSTALLATION/CONSTRUCTIONOTHERS (Specify)

BOX 7
PROGRESS FLOW
IN OUT PROCESSED BY:
DATE TIME DATE TIME
ELECTRICAL ENGINEER
ELECTRICAL 01/17/2021 7:30 AM 01/17/2021 10:30 AM (Signature Over Printed Name)
OTHERS (Specify) PRC Reg. No.: 1231231312
Validity: 2050

BOX 8
ACTION TAKEN

PERMIT IS HEREBY ISSUED SUBJECT TO THE FOLLOWING:

1. That is proposed electrical works shall be in accordance with the electrical plans filled with this Office and in
conformity with the provisions of the latest Philippine Electrical Codes, the National Building Code and its IRR.
2. That prior to any electrical installation, the Owner/Permittee shall submit a duly accomplished prescribed
Notice of Construction to the Office of the Building Official.
3. That for installed electrical capacity of 200 amperes and above 230 volts nominal and above, a specialty electrical
contractor duly licensed by the Philippine Contractors Accreditation Board (PCAB) shall be required.
4. That a duly licensed electrical practitioner shall be in-charge of the installation, and that upon completion of the electrical
works, he shall submit the entry of the logbook duly signed and sealed to the OBO including as-built plans and the other
documents. He shall also accomplish the Certificate of Completion starting that the electrical works conform to the
provisions of the Philippine Electrical Codes, the National Building Code and its IRR.
5. That this permit is null and void unless accomplished by the building permit except for projects involving purely
electrical works in which case only the building permit under of the existing building/structure shall be required.
6. That a Certificate of Final Electrical Inspection (CFEI) shall be secured prior to the actual occupancy of the building.
7. That this permit shall be posted at the door or site of work.

PERMIT ISSUED BY:

MICHEAL ANGELO
BUILDING OFFICIAL
(Signature Over Printed Name)
Date: January 10, 2021
 REPUBLIC OF THE PHILIPPINES
OFFICE OF THE BUILDING OFFICIAL
MANILA CITY
Manila
APPLICATION NO. DISTRICT / CITY/ MUNICIPALITY PERMIT NO.
1 2 3 4 5 6 7 8 9 AREA CODE 3123 1 2 1 1 1 1 1 1

MECHANICAL PERMIT
January 10, 2021
DATE OF APPLICATION DATE ISSUED

BOX 1 (TO BE ACCOMPLISHED BY PROFESSIONAL MECHANICAL ENGINEER IN PRINT)

NAME OF OWNER/APPLICANT LAST NAME, FIRST NAME M.I. TAX ACCOUNT NO.

ADDRESS NO., STREET, BARANGAY, CITY/MUNICIPALITY TELEPHONE NO.

LOCATION OF INSTALLATION NO., STREET, BARANGAY, CITY/MUNICIPALITY

SCOPE OF WORK
NEW INSTALLATION ADDITION OF BUILDING PERMIT No.
REMOVAL OF
OTHERS (SPECIFY) CERTIFICATE OF OCCUPANCY No.

USE OR TYPE OF OCCUPANCY

RESIDENTIAL AGRICULTURAL
COMMERCIAL LANDSCAPING
INDUSTRIAL OTHERS (SPECIFY)
INSTITUTIONAL

USE OR TYPE OF OCCUPANCY

BOILER CENTRAL AIR-CONDITIONING DUMBWAITER
PRESSURE VESSELS MECHANICAL VENTILATION PUMPS
INTERNAL COMBUSTION ENGINE ESCALATOR COMPRESSED AIR, VACUUM
REFRIGERATION & ICE MAKING MOVING SIDEWALK INSTITUTIONAL and/or INDUSTRIAL
WINDOW TYPE AIRCONDITION FREIGHT ELEVATOR GAS
PACKAGE AIR-CONDITIONING UNIT PASSENGER ELEVATOR PNUEMATIC TUBES, CONVEYORS
and/or MONORAILS
OTHERS (SPECIFY)

PROPOSED DATE EXPECTED DATE

OF INSTALLATION OF COMPLETION

TOTAL INSTALLATION COST PREPARED BY

ACTION TAKEN:

PERMIT IS HEREBY GRANTED TO INSTALL THE MECHANICAL EQUIPMENT

ENUMERATED HEREIN SUBJECT TO THE FOLLOWING CONDITIONS:

1. THAT THE PROPOSED INSTALLATION SHALL BE IN ACCORDANCE WITH

APPROVED PLANS FILED WITH THIS OFFICE AND IN CONFORMITY WITH
THE NATIONAL BUILDING CODE.
2. THAT A DULY LICENSED PROFESSIONAL MECHANICAL ENGINEER, BE
ENGAGED TO UNDERTAKE THE INSTALLATION/CONSTRUCTION.
3. THAT A CERTIFICATE OF COMPLETION DULY SIGNED BY A PROFESSIONAL
MECHANICAL ENGINEER IN CHARGE OF INSTALLATION SHALL BE
SUBMITTED NOT LATER THAN SEVEN (7) DAYS AFTER COMPLETION OF BUILDING OFFICIAL
THE INSTALLATION.
4. THAT A CERTIFICATE OF FINAL INSPECTION AND A CERTIFICATE OF

OCCUPANCY BE SECURED PRIOR TO THE ACTUAL OCCUPANCY OF THE DATE

BUILDING
5. THAT AN ANNUAL CERTIFICATE OF INSPECTION SHALL BE SECURED FOR
THE CONTINUOUS OPERATION OF THE MECHANICAL EQUIPMENT INSTALLED

NOTE:
THIS PERMIT MAY BE CANCELLED OR REVOKED PURSUANT TO SECTION 305&306 OF THE "NATIONAL BUILDING CODE"
 BOX 3 (TO BE ACCOMPLISHED BY THE RECEIVING & RECORDING SECTION)

BUILDING DOCUMENTS
(FIVE (5) SETS EACH)

MECHANICAL PLANS & SPECIFICATIONS BILL OF MATERIALS

COST OF ESTIMATES OTHERS (SPECIFY)

BOX 4 (TO BE ACCOMPLISHED BY DIVISION/SECTION CONCERNED)

ASSESSED FEES

AMOUNT DUE ASSESSED BY O.R. NUMBER DATE PAID

MECHANICAL

REVIEWED:

CHIEF, PROCESSING DIV./SEC/

BOX 5 (TO BE ACCOMPLISHED BY DIVISION/SECTION CONCERNED)

PROGRESS FLOW

NOTED: IN OUT

CHIEF, PROCESSING TIME DATE TIME DATE ACTION/REMARKS PROCESSED BY

DIVISION/SECTI

RECEIVING AND RECORDING

SANITARY
WE HEREBY AFFIX OUR HANDS SIGNIFYING OUR CONFORMITY TO THE INFORMATION HEREIN ABOVESETFORTH.

BOX 6 BOX 6

PROF. MECH. ENGINEER P.R.C. REG. SIGNATURE

SIGNED AND SEALED PLANS & SPECIFICATION No.

PRINT NAME
APPLICANT
ADDRESS
RES. CERT NO. DATE ISSUED PLACE ISSUED
P.T.R. No. DATE ISSUED PLACE ISSUED

SIGNATURE TIN

BOX 7

PROF. MECH. ENGINEER P.R.C. REG. No.

IN-CHARGE OF INSTALLATION

PRINT NAME

ADDRESS

P.T.R. No. DATE ISSUED PLACE ISSUED

SIGNATURE TIN
REPUBLIC OF THE PHILIPPINES

OFFICE OF THE BUILDING

OFFICIAL
BATANGAS CITY
APPLICATION PERMIT NO.
NO.

SANITARY/PLUMBING PERMIT
DATE OF APPLICANT DATE ISSUED

BOX 1 (TO BE ACCOMPLISHED BY SANITARY ENGINEERING/MASTER PLUMBER, IN PRINT)

NAME OF OWNER/APPLICANT LAST NAME, FIRST NAME M.I TAX ACCT. NO.

ADDRESS NO., STREET, BARANGAY, CITY/MUNICIPALITY TELEPHONE NO.

LOCATION OF INSTALLATION NO., STREET, BARANGAY, CITY/MUNICIPALITY

SCOPE OF WORK
NEW INSTALLATION ADDITION OF OTHERS (SPECIFY)
REPAIR OF OF
REMOVAL OF OF
USE OR TYPE OF OCCUPANCY
RESIDENTIAL AGRICULTURAL
COMMERCIAL PARKS, PLAZA, MONUMENTS
INDUSTRIAL RECREATIONAL
INSTITUTIONAL OTHERS(SPECIFY)
FIXTURES TO BE INSTALLED
NEW EXISTING KIND OF NEW EXISTING KIND OF
QTY. FIXTURES FIXTURES FIXTURES QTY. FIXTUR FIXTURES FIXTURES
WATER CLOSET BIDETTE
FLOOR DRAIN LAUNDRY TRAYS
LAVATORIES DENTAL CUSPIDOR
KITCHEN SINK GAS HEATER
FAUCET ELECTRIC HEATER
SHOWER HEAD WATER BOILER
WATER METER DRINKING FOUNTAIN
GREASE TRAP BAR SINK
BATH TUBS SODA FOUNTAIN SINK
SLOP SINK LABORATORY SINK
URINAL STERILIZER
AIR CONDITIONING UNIT SWIMMING POOL
WATER TANK/RESERVIOR OTHERS(SPECIFY)
TOTAL TOTAL
WATER DISTRIBUTION SYSTEM SANITARY SEWER SYSTEM STORM DRAINAGE SYSYTEM
WATER SUPPLY: SYSTEM OF DISPOSAL
SHALLOW WELL WASTE WATER TREAT PLANT SURFACE DRAINAGE
DEEP WELL& PUMP SET SEPTIC VAUL/IMHOFF TANK STREET CANAL
CITY/MUNICIPAL WATER SYSTEM SANITARY SEWER CONNECTION WATER
COURSE OTHERS SUB-SURFACE SAND FILTER

NUMBER OF STOREYS OF BUILDING TOTAL AREA OF

BUILDING/SU
BDIVISION
SQ. M.
PROPOSED DATE
START OF INSTALLATION TOTAL COST
EXPECTED DATE OF INSTALLATION P
OF COMPLETION PREPARED BY:

BOX 2 (TO BE ACCOMPLISHED BY BUILDING OFFICIAL)

ACTION TAKEN
PERMIT IS HEREBY GRANTED TO INSTALL THE SANITARY/PLUMBING FIXTURE
ENUMERATED HEREIN SUBJECT TO THE FOLLOWING CONDITIONS:

1. THAT THE PROPOSED INSTALLATION SHALL BE IN ACCORDANCE WITH

APPROVED PLANS FILED WITH THIS OFFICE AND IN CONFORMITY WITH
THE NATIONAL BUILDING CODE.
2. THAT A DULY LICENSED SANITARY ENGINEER, MASTER PLUMBER BE
ENGAGED TO UNDERTAKE THE INSTALLATION/CONSTRUCTION.
3. THAT A CERTIFICATE OF COMPLETION DULY SIGNED BY A SANITARY BUILDING OFFICIAL
ENGINEER/MASTER PLUMBER IN CHARGE OF INSTALLATION SHALL BE
SUBMITTED NOT LATER THAN SEVEN (7) DAYS AFTER COMPLETION OF
THE INSTALLATION. DATE
4. THAT A CERTIFICATE OF FINAL INSPECTION AND A CERTIFICATE OF
OCCUPANCY BE SECURED PRIOR TO THE ACTUAL OCCUPANCY OF THE
BUILDING

NOTE:
THIS PERMIT MAY BE CANCELLED OR REVOKED PURSUANT TO SECTION 305&306 OF THE "NATIONAL BUILDING CODE"
 BOX 3 (TO BE ACCOMPLISHED BY THE RECEIVING & RECORDING SECTION)

BUILDING DOCUMENTS
SANITARY PLUMBING PLANS & SPECIFICATIONS COST ESTIMATES

BILL OF MATERIALS OTHERS (SPECIFY)

BOX 4 (TO BE ACCOMPLISHED BY DIVISION/SECTION CONCERNED)

ASSESSED FEES
AMOUNT DUE ASSESSED BY O.R. NUMBER DATE PAID

BOX 5 (TO BE ACCOMPLISHED BY DIVISION/SECTION CONCERNED)

PROGRESS FLOW

NOTED: IN OUT
CHIEF, PROCESSING TIME DATE TIME DATE ACTION/REMARKS PROCESSED BY
DIVISION/SECTI
RECEIVING AND RECORDING

SANITARY

WE HEREBY AFFIX OUR HANDS SIGNIFYING OUR CONFORMITY TO THE INFORMATION HEREIN ABOVESETFORTH.

BOX 6 BOX 6

SANITARY ENGINEER/MASTER PLUMBER P.R.C. REG. No. SIGNATURE

SIGNED AND SEALED PLANS & SPECIFICATION
PRINT NAME
APPLICANT
ADDRESS
RES. CERT DATE ISSUED PLACE ISSUED
P.T.R. No. DATE ISSUED PLACE ISSUED NO.

SIGNATURE TIN

BOX 7

SANITARY ENGINEER/MASTER PLUMBER P.R.C. REG. No.

IN-CHARGE OF INSTALLATION

PRINT NAME

ADDRESS

P.T.R. No. DATE ISSUED PLACE ISSUED

SIGNATURE TIN