DPWH FORM NO.

95-002-E
Republic of the Philippines
Department of Public Works and Highways
Office of the Building Official

City of Bacoor
Province of Cavite
AREA CODE 04119

APPLICATION NO. DATE APPLICATION FILED:

APPLICATION FOR ELECTRICAL PERMIT

(Accomplished in Print and in Duplicate)
_____________________________ _____________________________
Date of Proposed Start of Installation Expected Date of Completion

BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE APPLICANT)

NAME OF OWNER / APPLICANT: LASTNAME FIRSTNAME MIDDLE NAME TIN

ADDRESS: NO. STREET BARANGAY CITY/MUNICIPALITY TELEPHONE NO.

LOCATION OF INSTALLATION: BLK LOT NO. STREET SUBDIVISION / BARANGAY

BACOOR CITY, CAVITE

SCOPE OF WORK

NEW INSTALLATION ADDITION OF ___________________________ OTHERS (SPECIFY)

ANNUAL INSPECTION REPAIR OF ___________________________ ___________________________
REMOVAL OF ___________________________ ___________________________

TYPE OF OCCUPANCY OR USE

A. RESIDENTIAL DWELLING E. BUSINESS & MERCHANTILE I. ASSEMBLY OCCUPANCY LOAD 1000 OR MORE

B. RESIDENTIAL, HOTEL, APARTMENT F. INDUSTRIAL J. ACCESORY

C. EDUCATIONAL & RECREATION G. STORAGE K. OTHERS (SPECIFY) ____________________________

D. INSTITUTIONAL H. ASSEMBLY OTHER THAN GROUP 1

NUMBER OF OUTLETS NUMBER OF EQUIPMENT / WIRING DEVICES
________ LIGHT ________ SPO, COOKING UNIT ________ TOGGLE SWITCH ________ FA DETECTORS
________ CONVENIENCE / RECEPTABLE ________ SPO, WATER HEATER ________ BELLS / BUZZER ________ OTHERS (see attached list)
________ SPO, AIRCON ________ SPO, WATER PUMP ________ PUSH BUTTONS

BOX 2 (PROFESSIONAL ELECTRICAL ENGINEER WHO SIGNED AND SEALED PLANS & SPECIFICATIONS)
NAME PRC REG. NO. VALIDITY

ADDRESS TELEPHONE NO.

PTR NO. DATE ISSUED PLACE ISSUED

SIGNATURE DATE SIGNED TIN

BOX 3 (ELECTRICAL CONTRACTOR – 200 AMPERE MAIN AND ABOVE)

NAME PCAB LIC. NO. (SPECIALTY ELECTRICAL)
VALIDITY
ADDRESS TELEPHONE NO.

SIGNATURE DATE SIGNED

BOX 4 (PERSON-IN-CHARGE OF INSTALLATION)

PROFESSIONAL ELECTRICAL ENGINEER REGISTERED ELECTRICAL ENGINEER REGISTERED MASTER ELECTRICIAN

(NOT EXCEEDING 600 VOLTS & 500KVA)
NAME PRC REG. NO. VALIDITY

ADDRESS TELEPHONE NO.

PTR NO. DATE ISSUED PLACE ISSUED

SIGNATURE DATE SIGNED TIN

BOX 5 (TO BE ACCOMPLISHED BY THE APPLICANT)

NAME SIGNATURE TIN
CTC NO. ____________________
DATE ISSUED ____________________
PLACE ISSUED ____________________

BOX 6 (TO BE RECEIVED BY RECEIVING / RECORDING SECTION)

RECEIVED BY: ________________________________________________

ELECTRICAL PLANS & SPECIFICATIONS (5 SETS) SIGNATURE OVER PRINTED NAME

DATE RECEIVED: ________________________________________________

DPWH FORM NO. 95-002-E

Republic of the Philippines

Department of Public Works and Highways
Office of the Building Official

City of Bacoor
Province of Cavite
AREA CODE 04119

PERMIT NO. APPLICATION NO.

DATE ISSUED _______________________ DATE FILLED _________________

PAID UNDER O.R. NO. _______________________
AMOUNT _______________________
DATE _______________________

ELECTRICAL PERMIT

BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE APPLICANT)

NAME OF OWNER / APPLICANT: LAST NAME FIRST NAME MIDDLE NAME TIN

ADDRESS: NO. STREET BARANGAY CITY/MUNICIPALITY TELEPHONE NO.

LOCATION OF INSTALLATION: BLK LOT NO. STREET SUBDIVISION / BARANGAY

BACOOR CITY, CAVITE

BOX 2 (TO BE ACCOMPLISHED BY THE DIVISION / SECTION CONCERNED)

ASSESED FEES
AMOUNT DUE ASSESED BY O.R. NO. DATE PAID

REVIEWED

CHIEF, PROCESSING DIV/SEC

BOX 3 (TO BE ACCOMPLISHED BY THE DIVISION / SECTION CONCERNED)

ACTION TAKEN:

PERMIT IS HEREBY GRANTED TO INSTALL THE ELECTRICAL W IRING, DEVICES AND EQUIPMENT ENUMERATED IN THE APPLICANT ION SUBJECT
TO THE FOLLOW ING CONDITIONS.

1. THAT THE PROPOSED INSTALLATIONS BE IN ACCORDANCE W ITH THE APPROVED PLANS FILED WITH THIS OFFICE AND IN CONFORMITY WITH
THE PROVISIONS OF THE LATEST EDITION OF THE PHILIPPINE ELECTRICAL CODE.

2. THAT A DULY LICENSED ELECTRICAL PRACTITIONER BE INCHARGDE OF THE INSTALLATION / CONSTRUCTION.

3. THAT A CERIFICATE OF COMPLETION DULY SIGNED BY THE ELECTRICAL PRATIOTIONER INCHARGE OF THE INSTALLATION BE SUBMITTED
NOT LATER THAN A SEVEN (7) DAYS AFTER COMPLETION OF THE INSTALLATION.

4. THAT A CERTIFICATE OF FINAL ELECTRICAL INSPECTION BE SECURED PRIOR TO THE ACTUAL OCCUPANCY OF THE BUILDING

5. THIS PERMIT SHALL BE POSTED AT THE DOOR OR SITE OF WORK.

RECOMMENDING APPROVAL:

ENGR. RODERICK C. JAVINAL / ENGR. BERNARDO L. MANALILI

ENGINEER II

APPROVED BY: NOTED BY:

ENGR. FELICITO R. MEJIA HON. LANI MERCADO-REVILLA

CITY BUILDING OFFICIAL CITY MAYOR

NOTE 1: This permit may be cancelled or revoked pursuant to Section 305 & 306 of the National Building Code
NOTE 2: Alterations on this form are not allowed