This Certificate of Operation: Air-Conditioning/Refrigeration is issued/granted pursuant to pertinent provision of rule iii

of the National Building Code, PD 1096.

NBC form no. M - 05 Name of Owner/Lessee Republic of the Philippines

City/Municipality of _____________________
Certificate of Inspection: Located at/along Province of __________________________________
No. of Units OFFICE OF THE BUILDING OFFICIAL
Gas Pipe and/or Burner Description
(Commercial, Industrial, Institutional)
Total HP Certificate of Operation:
Name of Owner/Lessee
Gas Pipe and/or Burner
The owner/lessee shall properly maintain the equipments/machineries to ensure its safe operation.
Located at/along
(Commercial, Industrial, Institutional)
No change, addition or alteration deviating from the original mechanical plans shall be made without appropriate permit.
No.
A certificate was submitted by _________________________________________ a duly The aforementioned air-conditioning/refrigeration
(Name) Fee Paid may now be operated for a period of one (1) year from the date of inspection.
licensed professional mechanical engineer hired by the owner who undertook the mechanical The owner/lessee of the building/structure Official
shall Receipt
notify inNo.
writing the office of the building official for the granting/issuance of a
Date Paid
inspection and that the installation is in order.
Certificate of Operation: Air-Conditioning/Refrigeration for a period of one (1) year from Datethe date of issuance of this
Issued
Verified as to the following
certificate and yearly thereafter.
This Certificate of Operation: Gas Pipe and/or Burner (Commercial, Industrial, Institutional) is issued/granted
Gas Pipe and/or Burner/use of Gas A certified
pursuant copyprovision
to pertinent hereof shall belatest
of the posted within the
Philippine premises code,
Mechanical of thethe
building and
National shall not
building be and
Code removed without authority
its Implementing Rules from the
Length, diameter, pipe schedule and description and regulations.
___________________________________________________________________ building official.
___________________________________________________________________ Name of Owner/Lessee ____________________________________________________________________
___________________________________________________________________ Located at/along _________________________________________________________________________
___________________________________________________________________
Protection provision Piping and/or Burner/use
Supply to Safety Device Capacity Length, diameter, pipe schedule and description:
_____________________ ______________________ _____________________ _________________________________________________________________________
_____________________ ______________________ _____________________ _________________________________________________________________________
_____________________ ______________________ _____________________ _________________________________________________________________________
_____________________ ______________________ _____________________
Protection provision:
Verified on ______________________________________________________________ Supply to Safety Device Capacity
Date of Expiration ______________________________________________________ ________________________ ________________________ ________________________
Inspection fee paid ______________________________________________________ ________________________ ________________________ ________________________
Official Receipt no. _____________________________________________________ ________________________ ________________________ ________________________
Date Issued ______________________________________________________________ The owner/lessee shall properly maintain the installation/device/equipment to ensure its safe use and operation.
The above described mechanical installation covered by Mechanical Permit No change, addition or upgrading/alteration deviating from the original mechanical plans shall be made without
No._________________ issued on_______________________ has been found substantially appropriate permit.
satisfactory complied, therefore the “Certificate of Operation: Gas Pipe and/or Burner
The aforementioned Gas Pipe and/or Burner (Commercial, Industrial, Institutional) may now be operated for a
(Commercial, Industrial, Institutional)” is hereby recommended for issuance.
period of one (1) year from the date of inspection.
The owner/lessee of the building/structure shall notify in writing the office of the building official for the
granting/issuance of a Certificate of Operation: Gas Pipe and/or Burner (Commercial, Industrial, Institutional)
for a period of one (1) year from the date of issuance of this certificate and yearly thereafter.
Mechanical Inspector Chief, Mechanical Section
(Signature Over Printed Name) (Signature Over Printed Name) A certified copy hereof shall be posted within the premises of the building and shall not be removed without authority
Date_______________________ Date_______________________ from the building official.
_______________ ______________ _______________ ______________
PRC Reg. No. validity PRC Reg. No. validity

Chief, Chief, BUILDING OFFICIAL

Inspection and Enforcement Division Processing and Evaluation Division (Signature Over Printed Name)
(Signature Over Printed Name) (Signature Over Printed Name) Date_________________________
Date________________________ Date_______________________