DPWH FORM NO. 96-002-E
DATE ISSUED : DATE FILED :PAID UNDER O.R. NO. :AMOUNT :DATE ISSUED :
BOX 1NAME OF OWNER/APPLICANT LAST NAME FIRST NAME MIDDLE NAME TIN
ADDRESS NO. STREET BARANGAY CITY/MUNICIPALITY TEL/FAX NO.
LOCATION OF INSTALLATION NO. STREET BARANGAY CITY/MUNICIPALITY
BOX 2
REVIEWED BY
BOX 3
PERMIT IS HEREBY GRANTED TO INSTALL THE ELECTRICAL WIRING, DEVICES AND EQUIPMENT ENUMERATED IN THISAPPLICATION SUBJECT TO THE FOLLOWING CONDITIONS :
THAT THE PROPOSED INSTALLATION BE IN ACCORDANCE WITH THE APPROVED PLANS FILED WITH THIS OFFICE AND INCONFORMITY WITH THE PROVISIONS OF THE LATEST EDITION OF THE PHILIPPINE ELECTRICAL CODE.
THAT A DULY LICENSED ELECTRICAL PRACTITIONER BE INCHARGE OF THE INSTALLATION/CONSTRUCTION
THAT CERTIFICATE OF COMPLETION DULY SINGED BY THE ELECTRICAL PRACTITIONER INCHARGE OF THE INSTALLATIONBE SUBMITTED NOT LATER THAN SEVEN (7) DAYS AFTER COMPLETION OF THE INSTALLATION.
THAT A CERTIFICATE OF FINAL ELECTRICAL INSPECTION BE OCCURRED PRIOR TO THE ACTUAL OCCUPANCY OF THE BUILDING
THIS PERMIT SHALL BE POSTED AT THE DOOR OR SITE OF WORK.
APPROVED :
NOTED :
loymi_lapuz_2000
Note 1: This permit maybe cancelled or revoked pursuant to Section 305-306 of the National Buildind Code.Note 2 : Alteration on this form are not allwed
ASSESSED BY O.R. NUMBER DATE PAID
DATE
DATE
ELECTRICAL ENGINEER OF THE BUILDING OFFICE(Signature over printed name)
PRC REG. NO. AND VALIDITY
ENGR. CIRINIA GRACE L. CATUBIG
Republic of the PhilippinesDEPARTMENT OF PUBLIC WORKS AND HIGHWAYS
OFFICE OF THE LOCAL BUILDING OFFICIAL
DISTRICT/CITY/MUNICIPALITYAREA CODE._________
PERMIT NO.
OFFICER-IN-CHARGE
ELECTRICAL PERMIT (To be accomplished by the Office Concerned)
APPLICATION NO.
CHIEF OF PROCESSING DIV.SEC.
54
1
23
ASSESSMENT
AMOUNT DUE
DPWH FORM NO. 96-001-E
BOX 1 ( TO BE ACCOMPLISHED BY DULY QUALIFIED ELECTRICAL PRACTITIONER)LAST NAME FIRST NAME MIDDLE NAME TIN
NO. STREET BARANGAY CITY/MUNICIPALITY
NO. STREET BARANGAY CITY/MUNICIPALITY
SCOPE OF WORKNEW INSTALLATION ADDITION OF __________ OTHERS (Specify)ANNUAL INSPECTION REPAIR OF _____________
REMOVAL _____________
TYPE OF OCCUPANCY OR USE:A. RESIDENTIAL DWELLING E. BUSINESS & MERCANTILE I. ASSEMBLY OCCUPANT LOAD 100 OR MORE
B. RESIDENTIAL HOTEL APARTMENT F. INDUSTRIAL J. ACCESSORYC. EDUCATION AND RECREATION G. STORAGE & HAZARDOUS K. OTHERS (Specify) D. INSTITUTIONAL H. ASSEMBLY OTHER THAN GROUP I
NUMBER OF OUTLETS NUMBER OF EQUIPMENT/WIRING DEVICESLIGHT SPO COOKING UNIT TOGGLE SWITCH FIRE ALARM/SMOKE DETECTORS
CONVINIENCE/RECEPTACLE SPO. COOKING HEATER BELLS BUZZER OTHERS (See attached List)SPO. AIRCON SPO WATER PUMP PUSH BOTTON
BOX 2 ( PROFESSIONAL ELECTRICAL ENGINEER WHO SIGNED AND SEALED THE PLANS & SPECIFICATION)
PRC REG. NO. VALIDITY
BOX 3 ( ELECTRICAL CONTRACTOR 200-AMPERE MAIN AND ABOVE
BOX 4 (PERSON IN-CHARGE OF INSTALLATION)REGISTERED ELECTRICAL ENGINEER REGISTERED MASTER ELECTRICIAN
(not exceeding 600 volts and 500 KVA)
PRC REG. NO. VALIDITY
BOX 5 (OWNER/AUTHORIZED REPRESENTATIVE)
BOX 6 ( TO BE RECEIVED BY RECEIVING/RECORDING SECTION)RECEIVED BY:
DATE RECEIVED:
ELECTRICAL PLANS & SPECIFICATIONS (5 SETS)Signature over printed Name
PROFESIONAL ENGINEER
NAME SIGNATURE TIN CTC NO.
DATE ISSUED
PLACE ISSUED
PTR NO. DATE ISSUED PLACE ISSUED
SIGNATURE DATE ISSUED TIN
( ) ( )
NAME
ADDRESS TEL/FAX NO.
( )
( ) ( )
DATE ISSUED TIN
NAME PCAB LIC. NO. (SPECIALTY - ELECTRICAL)
VALIDITY
( ) ( )
NAME
ADDRESS TEL/FAX NO.
APPLICATION NO. DATE FILED
Date of Proposed start of Installation Expected Date of Completion
( ) ( ) ( )
APPLICATION FOR ELECTRICAL PERMIT( Accomplished in print and in Duplicate)
NAME OF
OWNER/APPLICANT
ADDRESSTEL./FAX NO.
( ) ( )
Republic of the PhilippinesDEPARTMENT OF PUBLIC WORKS AND HIGHWAYS
OFFICE OF THE LOCAL BUILDING OFFICIAL
DISTRICT/CITY/MUNICIPALITYAREA CODE._________
( ) ( ) ( )
LOCATION OF
INSTALLATION
ADDRESS TEL./FAX NO.
PTR NO. DATE ISSUED PLACE ISSUED
SIGNATURE
( )( ) ( )
( )
( )
PAID UNDER O.R. NO. : Permit No.AMOUNT :DATE ISSUED :
BOX 1NAME OF OWNER/APPLICANT LAST NAME FIRST NAME MIDDLE NAME TIN
ADDRESS NO. STREET BARANGAY CITY/MUNICIPALITY TEL/FAX NO.
LOCATION OF INSTALLATION NO. STREET BARANGAY CITY/MUNICIPALITY
BOX 2PURPOSE:
CONSTRUCTION LIGHTING & POWER CEMETERY LIGHTING & POWER CARNIVALFIESTA LIGHTING & POWER
CHRISTMAS DECORATIVE LIGHTING OTHERS (Specify)
BOX 3
NUMBER OF OUTLETS : LIGHTS SWITCHES
OTHERS :
BOX 4
PROFESSIONAL ELECTRICAL ENGINEER REGISTERED ELECTRICAL ENGINEER REGISTERED MASTER ELECTRICIAN(not exceeding 600 Volts & 500 KVA)
NAME PRC REG. NO. VALIDITY
ADDRESS TEL/FAX NO.
PTR NO. DATE ISSUED PLACE ISSUED
SIGNATURE DATE ISSUED TIN
BOX 5
CTC NO.
DATE ISSUED
PLACE ISSUED
BOX 6
PERMIT IS HEREBY GRANTED TO CONNECT TEMPORARY ELECTRICAL INSTALLATION WITH THE AUTHORIZED LOAD SPECIFIED
ABOVE LOCATED AT FOR A PERIOD OF
DAYS FROM DATE
AFTER WHICH PERIOD THE SERVICE SHALL BE DISCONNECTED.
THIS PERMIT SHALL BE SUSPENDED OR REVOKED ANY TIME BEFORE ITS EXPIRATION WHENEVER ALTERATIONS ORCHANGES
IN THE ELECTRICAL WIRING SYSTEM HAVE RENDERED IT UNSAFE.
RECOMMENDING APPROVAL : APPROVED :
ELECTRICAL ENGINEER OF THE BUILDING OFFICIAL
loymi_lapuz_2000
Republic of the PhilippinesDEPARTMENT OF PUBLIC WORKS AND HIGHWAYS
OFFICE OF THE LOCAL BUILDING OFFICIAL
DISTRICT/CITY/MUNICIPALITYAREA CODE._________
ENGR. CIRINIA GRACE L. CATUBIG
PRC REG. NO. AND VALIDITY PRC REG. NO. AND VALIDITY
PERMIT FOR TEMPORARY SERVICE CONNECTION
PERSON IN-CHARGE OF INSTALLATION
OWNER/APPLICANT
NAME SIGNATURE TIN
Date
OFFICER IN-CHARGE
Aplication No. Date Received
Name of Applicant :
Project Location :
Contact Person :
Tel/Contact No. :
Application Letter; Photocopy of owner's valid ID with three (3) specimensignatures; authorization leeter.
Barangay Certification as Bonafide resident of the area.
Sketch/Vicinity Map/Location
Photo of the structure to be Connected
Affidavit of Undertaking.
If Temporary : Photocopy of Approved Building Permit.
Davao Light Electric Bill (Transfer location of Meter/Separation of Meter/Reconnection of Meter/Change of Service Entrance.)
Remarks by Electrical Inspector :
Name of Inspector :
Date of Inspection :
Reviewed by : Engr. DENNIS REUBEN C. JARANILLA / ENGR. ALPHEO JOSE BOLOTAOLO
Recommending Approved : ENGR. ROLANDO A. EBAD(ENGINEER III)
REPUBLIC OF THE PHILIPPINES
OFFICE OF THE BUILDING OFFICIAL
CITY GOVERNMENT OF DAVAO
CHECKLIST OF REQUIREMENTSTEMPORARY/REVOCABLE ELECTRICAL
(signature over printed name)
(ENGINEER II) (ENGINEER II)