REPUBLIC OF THE PHILIPPINES

QUEZON CITY
DEPARTMENT OF THE BUILDING OFFICIAL
APPLICATION FOR ELECTRICAL PERMIT
APPLICATION NO.
DATE OF APPLICATION:

BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE OWNER/APPLICANT AND BY THE DESIGN PROFESSIONAL)
OWNER/APPLICANT: LAST NAME FIRST NAME M.I. TIN

FOR CONSTRUCTION OWNED BY FORM OF OWNERSHIP USE OR CHARACTER OF OCCUPANCY

AN ENTERPRISE
ADDRESS NO. STREET, BARANGAY, CITY/MUNICIPALITY ZIP CODE TEL. NO.

LOCATION OF INSTALLATION: LOT NO.: _________________ BLK NO.: ______________________ TCT NO.: ______________ TAX DEC. NO.:_______________

STREET: ____________________________________________________________ BARANGAY: ______________________________________________________. QUEZON CITY

SCOPE OF WORK:
NEW INSTALLATION RECONNECTION OF KWHR METER RELOCATION OF KWHR METER
ANNUAL INSPECTION SEPARATION OF KWHR METER OTHERS (Specify)
TEMPORARY REMODEL OF SERVICE ENTRANCE

SUMMARY OF ELECTRICAL LOAD/CAPACITIES APPLIED FOR

TOTAL CONNECTED LOAD TOTAL TRANSFORMER CAPACITY TOTAL GENERATOR/UPS CAPACITY

kVA kVA kVA

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

PROFESSIONAL ELECTRICAL ENGINEER WHO SIGNED AND SEALED PLANS AND SPECIFICATION

Address:

PRC No. Validity

Date
PROFESSIONAL ELECTRICAL ENGINEER 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 & 500 kVa

Date:
(Signature over printed name)

PRC No. Validity

PTR No. Date Issued

Issued at TIN

Address:

BOX 4 BOX 5
APPLICANT: WITH CONSENT: LOT OWNER

(Signature Over Printed Name) (Signature Over Printed Name)

Date: Date:

Address: Address:

CTC No. Date Issued Place Issued CTC No. Date Issued Place Issued

BOX 6

Date:

APPLICANT
(Signature Over Printed Name)

Address:

CTC No. Date Issued Place Issued TIN

QCG-DBO-CPA02-V01
SCHEDULE DATE OF INSPECTION

1. 2. 3. 4.

ACTUAL CONNECTED LOADS

NAME OF APPLICANT: PERMIT #

ADDRESS:

1. Loads to be connected:

LIGHT SPO,COOKING UNIT TOGGLE FA DETECTORS

CONVENIENCE/RECEPTACLE SPO,WATER HEATER BELL/BUZZER OTHERS

(See Attached List)
SPO, AIRCON SPO,WATER PUMP PUSH BUTTON

2. Nature of Works: Main CB: NO. of Circuit

3. Type of Service: Voltage: PH: Size of S.E. Conductor:

4. Remarks:

I hereby certify that the above data and information are true and correct to the best of my knowledge and belief:
Person In-charge of Installation
ELECTRICAL FEES
PEE/REE/RME (Signed and Sealed Over Printed Name)

ADDRESS
Fee P
Surcharge P PRC REG. NO.: VALIDITY:
Total P PTR NO.: TIN:
CTC NO. DATE ISSUED:

ISSUED PLACED ISSUED:

WORKSHEET
LOADS

Nature of Work:
INSPECTOR: REMARKS:

Signature over Printed Name

Fee: P DATE: TIME:

Paid under Official Receipt No. Performed in the presence of:

Date: Owner/ Applicant/ Representative:

RECOMMENDING APPROVAL:

APPROVED: NOTED:

ENGR.MICHAEL B. MACTAL, REE ENGR. ISAGANI R. VERZOSA JR.

ENGINEER III LOCAL BUILDING OFFICIAL
ELECTRICAL ENGINEER OF THE BUILDING OFFICIAL

Signature over Printed Name

NOTE: Renewal or extension of this permit and / or final certification of the electrical installation are subject and payment of corresponding fees in conformation with pertinent of the “National Building Code” (p.d. 1096)
And its implementing rules and regulations.

QCG-DBO-CPA02-V01