DPWH FORM NO.

77-001-S

DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS METROPOLITAN MANILA COMMISION

APPLICATION NO.

REPUBLIC OF THE PHILIPPINES

OFFICE OF THE BUILDING OFFICIAL

DISTRICT / CITY / MUNICIPALITY AREA CODE

PERMIT NO.

DATE OF APPLICATION

SANITARY/PLUMBING PERMIT
LAST NAME, FIRST NAME, M.I. NO., STREET, BARANGAY, CITY / MUNICIPALITY

DATE OF APPLICATION

BOX 1 (TO BE ACCOM[PLISHED BY SANITARY ENGINEER/MASTER PLUMBER IN PRINT NAME OF OWBER / APPLICANT TAX ACCT. NO

ADDRESS

TAX ACCT. NO

LOCATION OF INSTALLATION

NO., STREET, BARANGAY, CITY / MUNICIPALITY

SCOPE OF WORK NEW INSTALLATION

ADDITION OF REPAIR OF REMOVAL OF

OTHERS (SPECIFY) OF OF

USE OR TYPE OF OCCUPANCY

RESIDENTIAL COMMERCIAL INDUSTRIAL INSTITUTIONAL AGRICULTURAL PARKS, PLAZAS, MONUMENTS RECREATIONAL OTHERS (SPECIFY)

FIXTURES TO BE INSTALLED
QTY. NEW FIXTURES EXISTING FIXTURES KIND OF FIXTURES WATER CLOSET FLOOR DRAIN LAVATORIES KITHCEN SINK FAUCET SHOWER HEAD WATER METER GREASE TRAP BATH TUBS SLOP SINK URINAL AIR CONDITIONING UNIT WATER TANK/RESERVOIR TOTAL WATER DISTIBUTION SYSTEM SANITARY SEWER SYSTEM STORM DRAINAGE SYSTEM QTY. NEW FIXTURES EXISTING FIXTURES KIND OF FIXTURES BIDETTE LAUNDRY DENTAL CUSPIDOR GAS HEATER ELECTRIC HEATER WATER BOILER DRINKING FOUNTAIN BAR SINK SODA FOUNTAIN SINK LABORATORY SINK STERILIZER SWIMMING POOL OTHERS SPECIFY

WATER SUPPLY
SHALLOW WELL DEEP WELL & PUMP SET CITY/MUNICIPAL WATER SYSTEM OTHERS NUMBER OF STOREYS OF BUILDING

SYSTEM OF DISPOSAL
WASTE WATER TREATMENT PLANT SEPTIC VAULT/IMHOFF SANITARY SEWER CONNECTION SUB-SURFACE SAND FILTER SURFACE DRAINAGE STREET CANAL WATER COURSE

TOTAL AREA OF BUILDING/SUBDIVISION SQ.M

PROPOSED DATE PROPOSED DATE EXPECTED DATE OF COMPLETION BOX 2 (TO BE ACCOM[PLISHED BY THE BUILDING OFFICIAL

TOTAL COST OF INSTALLATION PREPARED BY

ACTION TAKEN:
PERMIT IS HEREBY GRANTED TO INSTALL THE SANITARY / PLUMBING FIXTURE ENUMERATED HEREIN SUBJECT TO THE FOLLOWING CONDITIONS: 1. 2. 3. THAT THE PROPOSED INSTALLATION SHALL BE IN ACCORDANCE WITH APPROVED PLANS FILED WITH THIS OFFICE AND IN CONFORMITY WITH THE NATIONAL BUILDTHAT A DULY LICENSED SANITARY ENGINEER / MASTER PLUMBER BE ENGAGED TO UNDERTAKE THE INSTALLATION / CONSTRUCTION. THAT A CERTIFICATE OF COMPLETION DULY SIGNED BY A SANITARY ENGINEER / MASTER PLUMBER IN-CHARGE OF INSTALLATION SHALL BE SUBMITED NOT LATER THAN SEVEN (7) DAYS AFTER COMPLETION OF THE INSTALLATION.

CHIEF, SANITARY & PLUMBING DIVISION ENGR. ISAGANI R. VERZOSA JR. BUILDING OFFICIAL

4. THAT A CERTIFICATE OF FINAL INSPECTION AND A CERTIFICATE OF OCCUPANCY OF THE BUILDING.

NOTE:

THIS PERMIT MAY BE CANCELLED OR REVOKED PURSUANT TO SECTIONS 305 & 306 OF THE NATIONAL BUILDING CODE

www.quezoncity.gov.ph DATE OFFICE OF THE BUILDING OFFICIAL

ORIGINAL-APPLICANTS COPY, PINKTREASURERS COPY, YELLOW-NCSO COPY, BLUE-BUILDING OFFICIALS COPY, GREEN-ACID COPY

BOX 3 (TO BE ACCOM[PLISHED BY THE RECEIVING & RECORDING SECTION

BUILDING DOCUMENTS
NEW INSTALLATION BILL OF MATERIALS COST ESTIMATES OTHERS (SPECIFY)

BOX 4 (TO BE ACCOM[PLISHED BY THE DIVISION/SECTION CONCERNED

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

BOX 5 (TO BE ACCOM[PLISHED BY THE DIVISION/SECTION CONCERNED

PROGRESS FLOW
NOTED, CHIEF, PROCESSING DIVISION/SECTION RECEIVING AND RECORDING GEODETIC (LINE and GRADE) SANITARY WE HEREBY AFFIX OUR HANDS SIGNIFYING OUR CONFORMITY TO THE INFORMATION HEREIN ABOVE SETFORTH BOX 6 BOX 6 PRC. REG. NO. SIGNATURE IN TIME DATE TIME IN DATE ACTION/ REMARKS PROCESSED BY

SANITARY ENGINEER/MASTER PLUMBER

SIGNED AND SEALED PLANS & SPECIFICATIONS PRINT NAME

APPLICANT ADDRESS ADDRESS P.T.R. NO. SIGNATURE DATE ISSUED TIN PLACE ISSUED RES. CERT. NO. DATE ISSUED PLACE ISSUED

BOX 7

SANITARY ENGINEER/MASTER PLUMBER

IN-CHARGE OF INSTALLATION PRINT NAME

PRC. REG. NO.

ADDRESS ADDRESS P.T.R. NO. SIGNATURE DATE ISSUED TIN PLACE ISSUED

www.quezoncity.gov.ph OFFICE OF THE BUILDING OFFICIAL