This is for DILG-DPWH-DICT-DTI JMC 2018-01
Republic of the Philippines Department of Public Works and Highways
City/Municipality of Province of OFFICE OF THE BUILDING OF
UNIFIEDAPPLICATION FORM FOR BUILDING PERMIT AND FIRE SAFETY EVAL
CLEARANCE
NEW RENEWAL AMENDATORY
APPLICATION NO. AREA NO.
BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE APPLICANT) D
BOX 2 O
N
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F
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OWNER/ APPLICANT LAST NAME FIRST NAME M.I. TIN
FOR CONSTRUCTION OWNED BY AN FORM OF OWNERSHIP
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
ACCESSORY BUILDING/STRUCTURE
ADDITION REPAIR OTHERS
(Specify)
ALTERATION
MOVING
USE OR CHARACTER OF OCCUPANCY
GROUP A : RESIDENTIAL, DWELLINGS GROUP F : INDUSTRIAL OTHERS (Specify) _ GROUP B
: RESIDENTIAL HOTEL, APARTMENT GROUP G : INDUSTRIAL STORAGE AND HAZARDOUS
GROUP C : EDUCATIONAL, RECREATIONAL GROUP H : RECREATIONAL, ASSEMBLY OCCUPANT LOAD LESS THAN 1000
GROUP D : INSTITUTIONAL GROUP I : RECREATIONAL, ASSEMBLY OCCUPANT LOAD 1000 OR MORE GROUP
E : BUSINESS AND MERCANTILE GROUP J : AGRICULTURAL, ACCESSORY
OCCUPANCY CLASSIFIED TOTAL ESTIMATED COST P
NUMBER OF UNITS PROPOSED DATE OF CONSTRUCTION
TOTAL FLOOR AREA SQUARE METERS EXPECTED DATE OF COMPLETION
LOT AREA SQUARE METERS
FULL-TIME INSPECTOR AND SUPERVISOR OF CONSTRUCTION WORKS (REPRESENTING THE OWNER)
Address
ARCHITECT OR CIVIL ENGINEER
PRC No. Validity
(Signed and Sealed Over Printed Name)
Date
PTR No. Date Issued
Issued at TIN
BOX 3
BOX 4
APPLICANT: WITH MY CONSENT: LOT OWNER / AUTHORIZED REPRESEN
Date Date
(Signature Over Printed Name) (Signature Over Printed Name)
Address Address
CTC No Date Issued Place Issued CTC No Date Issued
BOX 5
REPUBLIC OF THE PHILIPPINES ) S.S CITY/MUNICIPALITY OF )
BEFORE ME, at the City/Municipality of , on personally appeared the followi
APPLICANT
C.T.C. No. Date Issued Place Issued
LICENSED ARCHITECT OR CIVIL ENGINEER C.T.C. No. Date Issued Place Issued
(Full-Time Inspector and Supervisor of Construction Works)
whose signatures appear hereinabove, known to me to be the same persons who executed this standard prescribed form and acknowledged to me that the sam
free and voluntary act and deed.
WITNESS MY HAND AND SEAL on the date and place above written.
Doc. No.
Page No.
Book No. NOTARY PUBLIC (Until December )
Series of
Copy 1: Owner Copy 2: OBO Copy 3: BFP Copy 4: Philippine Statistics Authority
THE BUILDING OFFICIAL
E SAFETY EVALUATION
Validity
Date Issued
TIN
/ AUTHORIZED REPRESENTATIVE
Date
r Printed Name)
Place Issued
)
ersonally appeared the following:
knowledged to me that the same is their
ecember )
BOX 6 (TO BE ACCOMPPLISHED BY THE PROCESSING AND EVALUATION DIVISION)
ASSESSED FEES BASIS OF AMOUNT
ASSESSMENT DUE
FILING FEE
PROCESSING FEE
LOCATIONAL / ZONING OF LAND
USE
LINE AND GRADE (Geodetic)
FENCING
ARCHITECTURAL
CIVIL / STRUCTURAL
ELECTRICAL
MECHANICAL
SANITARY
PLUMBING
ELECTRONICS
INTERIOR
FIRE CODE CONSTRUCTION TAX
SURCHARGES
PENALTIES
TOTAL
TERMS AND CONDITIONS
1. The Owner/Permittee shall accomplish the prescribe Unified Application Form, with the assistance of the
concerned design professional/s and/or the Architect/Civil Engineer, hired/commissioned by the Owner/Permittee as
time inspector/supervisor of the construction works, by filling up the necessary data / information required thereat.
2. The fully accomplished prescribed Unified Application Form, duly notarized, shall be submitted to the concerned
Office of the Building Official accompanied by the various applicable ancillary and accessory permits, plans and
specifications signed and sealed by the corresponding design professionals who shall be responsible for the
comprehensive and correctness of the plans in compliance to the National Building Code (PD 1096), its IRR and to
applicable referral codes and professional regulatory laws, together with the other documentary
requirements pursuant to Section 302 of PD 1096 and its IRR.
ASSESSED BY
with the assistance of the
ed by the Owner/Permittee as full-
formation required thereat.
e submitted to the concerned
ssory permits, plans and
be responsible for the
de (PD 1096), its IRR and to all
r documentary
