MGB Form No.

08-3A

Republic of the Philippines

PROVINCIAL MINING REGULATORY BOARD (PMRB)
Province of Lanao del Norte

APPLICATION FOR
COMMERCIAL SAND AND GRAVEL PERMIT

Application No. _______________________ Date Filed ______________________

Applicant ARMANDO D. MATA SR
Address PUROK 2, MALINGAO, TUBOD, LANAO DEL NORTE
Size of Applied Area (hectares) 1.2 HECTARES

The Provincial Governor

Provincial Mining Regulatory Board
Province of Lanao del Norte

Madam:

In accordance with the provisions of the Philippine Mining Act of 1995 and its
revised Implementing Rules and Regulations, the undersigned ARMANDO D. MATA
SR., hereby applies for a Commercial Sand and Gravel Permit to remove and dispose
12,000 cubic meters of materials authorized thereunder from the tract of land
bounded as follows:

Beginning at a point “1” on the sketch plan, Tie Line from BLLM No. 169, PLS-13
to Corner “1” S 31-56°,W, 284.31 meters with Latitude 7° 55’ 23.89” and
Longitude 124° 55’ 40.30” W bounded by a point mark as follows:
TECHNICAL DESCRIPTION

Lines Bearing Distance, m. Lines Bearing Distance, m.

1-2 S 34° 54’ E 19.90 9-10 N 07° 32’ E 11.51
2-3 S 57° 24’ W 201.53 10-11 S 85° 01’ E 146.28
3-4 S 75° 47’ W 230.34 11-12 N 78° 35’ E 24.98

4-5 N 84° 53’ W 140.58 12-13 N 26° 55’ E 37.66

5-6 S 69° 38’ W 60.40 13-14 N 64° 18’ E 75.57

6-7 S 40° 51’W 47.97 14-15 S 86° 22’ E 152.32

7-8 S 81° 27’ W 46.38 15-16 N 75° 47’ E 222.32

8-9 N 84° 33’ W 134.29 16-1 N 57° 24’ E 103.56

with an approximate area of 1.2 hectares.

The area applied for is public and/or private land, lake, river, stream, creek or
other public waters (underline applicable term), located in the Sitio of TUGAYA,
Barangay of DALAMA , Municipality of TUBOD , Province of LANAO DEL
NORTE , Island of MINDANAO , Philippines.

1. The application fee of _________________________ has been paid under

Official Receipt No. ____________ dated __________________, Philippines.

2. The applicant binds himself or itself to pay the amount of _________________

(P______________) covering the total fee for the materials applied for, and to
file a __________________________ bond (surety, cash or personal) in the
amount of ________________(P ____________);

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3. This application is filed for the exclusive use and benefit of the applicant, and not
either directly or indirectly for the benefit of any other persons, corporation or
partnership, and for the sole purpose of removing and disposing of the said
materials;

4. The applicant agrees that the statements made in the application or made later in
support thereof shall be considered as conditions and essential parts of the permit
that may be granted by virtue thereof, and any falsehood in these statements on
omission of facts which may later change or affect substantially the facts set forth
in said statements shall be sufficient cause for the cancellation of the permit
granted.

The foregoing statements are hereby certified to be true to the best of the
applications knowledge and belief.

I, ARMANDO D. MATA SR., the person executing this affidavit for this
application, being first duly sworn, depose and say: that I have read or have caused the
foregoing application read to me; that I thoroughly understand the same; that each and
every statement in said application is true and correct.

ARMANDO D. MATA SR.

Applicant

TIN 114-785-714

ACKNOWLEDGEMENT

Republic of the Philippines)

Cagayan de Oro City ) S. S.

SUBSCRIBED AND SWORN to before me at the place aforesaid, on this

__________ day of ____________________, 20_____. The affiant exhibited to me his
Driver’s License with No. KO2-82-007682 valid until March 28, 2024.

___________________________
NOTARY PUBLIC

Doc. No. _______

Page No. _______
Book No. _______
Series of _______

INSTRUCTION

1. This application shall be accomplished in quintuplicate, two copies to be retained

by the applicant, the original and one copy to be forwarded to the Provincial/City
Mining Regulatory Board, and the remaining copy for the files of the MGB
Regional Office.
2. All pertinent information required shall be given, inapplicable word canceled, and
all blanks shall be filled up.

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3. Application not accompanied with all the required documents shall not be
accepted.