Republic of the Philippines)

Municipality of Talibon ) Sc.

AFFIDAVIT OF UNDERTAKING

I, __________________________________ of legal age and a resident of

___________________________, do hereby depose and state that:

1. I am the __________________ of _________________________________________

located at _______________________________. (Attach the authorization of the
owner/occupant in case of representative or in case of corporation board resolution
authorizing the affiant to execute this affidavit of undertaking)

2. At the time of my application for Business Permit for the said establishment/building, no
substantial changes which may affect the fire safety compliance or which may change
the nature of use or types of occupancy, or changes on the location of the said
establishment/building have been made from the time it was issued with fire Safety
Inspection Certificate (FSIC) or Occupancy permit last ________________________.

3. That I am executing this affidavit for the purpose of applying for FSIC for Business Permit
and to attest the truth of the foregoing facts.

In witness whereof, I have hereunto affixed my signature this ________ day of

_________________at __________________________.

__________________

SUBSCRIBE AND SWORN TO before me this _____ day of ___________________ affiant

exhibiting to me his _____________________ issued at __________________ on
_________________, to expire on _____________________ as competent evidence of identity.

Doc No. ______

Page No.:_____
Book No._____
Series of _____