ELECTRONIC NBC FORM NO.

A - 03
FIRE ALARM
SYSTEM Republic of the Philippines
City/Municipality of Madridejos
Province of Cebu
OFFICE OF THE BUILDING OFFICIAL

ELECTRICAL PERMIT
APPLICATION NO. EP NO BUILDING PERMIT NO.

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

LOCATION OF CONSTRUCTION: LOT NO. _______________ BLK NO. ________________ TCT NO. ______________________ TAX DEC. NO. ____________________
STREET___________________ BARANGAY ____________________________________________________ CITY/ MUNICIPALITY OF ________________________________

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 LOADS/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: CEBU CITY

PRC. No: 920 Validity: 11-19-21
BEETHOVEN P. DELIARTE Date____________
PROFESSIONAL ELECTRICAL ENGINEER PTR. No:233971 Date Issued:1-3-19
(Signed and Sealed Over Printed Name)
Issued at: CEBU CITY TIN: 103-789-519

BOX 3
SUPERVISOR / IN-CHARGE OF ELECTRICAL WORKS

PROFESSIONAL ELECTRICAL ENGINEER REGISTERED ELECTRICAL ENGINEER REGISTERED MASTER ELECTRICIAN

BEETHOVEN P. DELIARTE Date______________

(Signed and Sealed Over Printed Name)

PRC. No: 920 Validity: 11-19-21

PTR. No: 233971 Date Issued: 1-3-19
Issued at: CEBU CITY TIN: 103-789-519
Address: CEBU CITY

BOX 4 BOX 5
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 Issued Place Issued