Republic of the Philippines

Quezon City
DEPARTMENT OF THE BUILDING OFFICIAL
APPLICATION FOR ELECTRICAL PERMIT

APPLICATION NO. DATE OF APPLICATION: 03/08/2021

BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE OWNER/APPLICANT AND BY THE DESIGN PROFESSIONAL

OWNER/APPLICANT LAST NAME FIRST NAME M.I.

LEE GARY L
FORM OF OWNERSHIP TELEPHONE NO.
OWNER
ADDRESS NO. STREET BARANGAY CITY/MUNICIPALITY ZIP CODE

LOCATION OF CONSTRUCTION: LOT NO: 3 BLK NO: 5 TCT NO: TAX DEC. NO.:

STREET: E.RODRIGUEZ SR BARANGAY IMMACULATE CONCEPCION QUEZON CITY

SCOPE OF WORK:
NEW INSTALLATION ü RECONECTION RELOCATION

TRANSFER OF SERVICE ADDITIONAL METE REMODEL

TEMPORARY PERIMETER/SECURITY LIGHT NET METERING.

AS-BUILT FIRE VICTIM OTHERS (Specify)

SUMMARY OF ELECTRICAL LOAD/CAPACITIES APPLIED FOR

TOTAL CONNECTED LOAD TOTAL TRANSFORMER CAPACITY TOTAL GENERATOR CAPACITY

kVA kVA kVA

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

PROFESSIONAL ELECTRICAL ENGINEER WHO SIGNED AND SEALED PLANS AND SPECIFICATIONS

ADDRESS

PRC NO. VALIDITY

PROFESSIONAL ELECTRICAL ENGINEER Date PTR NO. DATE ISSUED

(Signed and Sealed Over Printed Name)
Issued at: TIN

BOX 3

SUPERVISOR IN-CHARGE OF INSTALLATION

PROFESSIONAL ELECTRICAL ENGINEER REGISTERED ELECTRICAL ENGINEER REGISTERED MASTER ELECTRICIAN

Not Exceeding 600 V & 500k VA

(Signed and Sealed Over Printed Name) Date

PRC NO. VALIDITY

PTR NO. DATE ISSUED

Issued at: TIN

ADDRESS

BOX 4 BOX 5
APPLICANT: WITH CONSENT: LOT OWNER

(Signed and Sealed Over Printed Name) (Signed and Sealed Over Printed Name)

Date
Date

ADDRESS ADDRESS

CTC No. Date Issued: Place Issued: CTC No. Date Issued: Place Issued:
BOX 6
REPUBLIC OF THE PHILIPPINES

CITY/MUNICIPALITY OF

BEFORE ME, at the City/Municiplity of on personally

append the following:

APPLICANT: CTC NO. DATE ISSUED PLACE ISSUED

LICENSED ARCHITECT OR CIVIL CTC NO. DATE ISSUED PLACE ISSUED

(Full Time Inspector and Supervisor of Construction Work)
ENGINEER

Whose signature appear hereinabove, known to me, to be the same peron who executed this standard prescribed form and acknowledged to that the same is their
free and voluntary act and deed.

WITNESS MY HAND AND SEAL on the date and place above written.

Doc. No.

Page. No.

Book No.
NOTARY PUBLIC (Until December ______________________ )
Series of.