NBC FORM NO.
A -06
Form No. MEO-012-Ø
Republic of the Philippines
City/Municipality of Guiguinto
Province of Bulacan
OFFICE OF THE BUILDING OFFICIAL
PLUMBING/SANITARY PERMIT
APPLICATION NO. PLUMBING/SANITARY PERMIT NO BUILDING PERMIT NO.
BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE OWNER/APPLICANT)
OWNER/APPLICANT LAST NAME FIRST NAME M.I. TIN
FOR CONSTRUCTION OWNED FORM OF OWNERSHIP USE OR CHARACTER OF OCCUPANCY
BY AN ENTERPRISE
ADDRESS: NO., STREET, BARANGAY, CITY/MUNICIPALITY ZIP CODE TELEPHONE NO
LOCATION OF CONSTRUCTION: LOT NO. _______________ BLK NO. ________________ TCT NO. ______________________ TAX DEC. NO. _____________________
STREET___________________ BARANGAY ____________________________________________________ CITY/ MUNICIPALITY OF ________________________________
SCOPE OF WORK
NEW CONSTRUCTION RENOVATION ________________________ RAISING________________________________________
ERECTION CONVERSION ________________________ DEMOLITION ____________________________________
ADDITION REPAIR _____________________________ ACCESSORY BUILDING/STRUCTURE ________________
ALTERATION MOVING _____________________________ OTHERS (Specify)_________________________________
BOX 2 (TO BE ACCOMPLISHED BY THE DESIGN PROFESSIONAL)
FIXTURES TO BE INSTALLED INSTALLATION AND OPERATION OF:
QTY. NEW EXISTING KIND OF QTY. NEW EXISTING KIND OF
FIXTURES FIXTURES FIXTURES FIXTURES FIXTURES FIXTURES WATER SUPPLY: SYSTEM OF DISPOSAL:
WATER CLOSET BIDETTE SHALLOW WELL WASTE WATER TREATMENT PLANT
FLOOR DRAIN LAUNDRY TRAYS
DEEP WELL & PUMP SET IMHOFF TANK
LAVATORY DENTAL CUSPIDOR
KITCHEN SINK DRINKING FOUNTAIN CITY/MUNICIPAL WATER SYSTEM SANITARY SEWER CONNECTION
FAUCET BAR SINK SUB-SURFACE SAND FILTER
OTHERS (Specify)
SHOWER HEAD SODA FOUNTAIN SINK
SURFACE DRAINAGE
WATER METER LABORATORY SINK __________________________
GREASE TRAP STERILIZER STREET CANAL
BATH TUB OTHERS (Specify)
WATER COURSE
SLOP SINK __________________________
__________________________ OTHERS (Specify)
URINAL
AIR CONDITIONING UNIT __________________________
__________________________
WATER TANK/RESERVOIR __________________________
TOTAL TOTAL
WATER DISTRIBUTION SYSTEM SEWAGE SYSTEM SEPTIC TANK STORM DRAINAGE SYSTEM
PREPARED BY: ______________________________________________________________________________________________________________________________
BOX 3 BOX 4
DESIGN PROFESSIONAL, PLANS AND SPECIFICATIONS SUPERVISOR / IN-CHARGE OF PLUMBING / SANITARY WORKS
MASTER PLUMBER / SANITARY ENGINEER MASTER PLUMBER / SANITARY ENGINEER
(Signed and Sealed Over Printed Name) (Signed and Sealed Over Printed Name)
Address Address
PRC. No Validity PRC. No Validity
PTR. No Date Issued PTR. No Date Issued
Issued at TIN Issued at TIN
BOX 5 BOX 6
BUILDING OWNER WITH MY CONSENT: LOT OWNER
(Signature Over Printed Name) (Signature Over Printed Name)
Date_________________ Date__________________
Address Address
C.T.C. No. Date Issued Place Issued C.T.C. No. Date Issued Place Issued
TO BE ACCOMPLISHED BY THE PROCESSING AND EVALUATION DIVISION
BOX 7
RECEIVED BY: DATE:
FIVE (5) SETS OF PLUMBING DOCUMENTS
PLUMBING / SANITARY PLANS AND SPECIFICATIONS COST ESTIMATES
BILL OF MATERIALS OTHERS (Specify)
___________________________________________
_____________________________
BOX 8
ASSESSED BY: IN OUT
PROCESSED BY
DATE TIME DATE TIME
AMOUNT DUE:
O.R. NUMBER
DATE PAID:
BOX 9
ACTION TAKEN:
PERMIT IS HEREBY ISSUED SUBJECT TO THE FOLLOWING:
1. That the proposed plumbing / sanitary works shall be in accordance with the plumbing /
sanitary plans filed with this Office and in conformity with the Revised Plumbing Code,
Code on Sanitation of the Philippines, the National Building Code and its IRR.
2. That prior to any commencement of plumbing / sanitary works, a duly accomplished
prescribed “Notice of Construction” shall be submitted to the Office of the Building
Official.
3. That upon completion of the plumbing / sanitary works, the licensed supervisor/in-charge
shall submit the entry to the logbook duly signed and sealed to the building official
including as-built plans and other documents and shall also accomplish the Certificate of
Completion stating that the plumbing / sanitary works of the building conform to the
provision of the Revised Plumbing Code, Code on Sanitation of the Philippines, the National
Building Code and its IRR.
4. That
PERMIT this permit
ISSUED BY: is null and void unless accompanied by the building permit.
ARCADIO LEOVER P. SULIT
BUILDING OFFICIAL
(Signature Over Printed Name)
Date ____________________
