ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAEAFAGAHAIAJAKALAMANAO
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NBC FORM NO. A - 04
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Republic of the Philippines
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City of San Fernando
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Province of La Union
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OFFICE OF THE BUILDING OFFICIAL
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MECHANICAL PERMIT
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APPLICATION NO.
MP NO.
BUILDING PERMIT NO.
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BOX 1 (TO BE ACCOMPLISHED BY THE OWNER/APPLICANT)
DOWNLOADABLE BUILDING PERMIT FORMS FOR SAN FERNANDO LA UNION
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OWNER/APPLICANT
LAST NAME
FIRST NAME
MI.
TIN
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FOR CONSTRUCTION OWNED
FORM OF OWNERSHIP
USE OR CHARACTER OF OCCUPANCY
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BY AN ENTERPRISE
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ADDRESS
NO.,
STREET, BARANGAY,
CITY/MUNICIPALITY OF
ZIP CODE
TELEPHONE NO.
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LOCATION OF CONSTRUCTION: LOT NO. _________ BLK NO. _________ TCT NO. _____________ TAX DEC NO. _____________
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STREET __________
BARANGAY ______________________________
CITY OF SAN FERNANDO, LA UNION
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SCOPE OF WORK
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NEW CONSTRUCTION
RENOVATION ___________________
RAISING _______________________________
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ERECTION
CONVERSION___________________
DEMOLITION ___________________________
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ADDITION
REPAIR ________________________
ACCESSORY BUILDING/STRUCTURE ______
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ALTERATION
MOVING ________________________
OTHERS (Specify) _______________________
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BOX 2 (TO BE ACCOMPLISHED BY THE DESIGN PROFESSIONAL
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INSTALLATION AND OPERATION OF:
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BOILER
CENTRAL AIRCONDITIONING
DUMBWAITER
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PRESSURE VESSEL
MECHANICAL VENTILATION
PUMPS
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INTERNAL COMBUSTION ENGINE
ESCALATOR
COMPRESSED AIR, VACUUM, INSTITUTIONAL and/or INDUSTRIAL GAS
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REFRIGERATION AND ICE MAKING
MOVING SIDEWALK
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WINDOW TYPE AIRCONDITIONING
FREIGHT ELEVATOR
PNEUMATIC TUBES, CONVEYORS and/or MONORAILS
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PACKAGED/SPLIT TYPE AIRCONDITIONING
PASSENGER ELEVATOR
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OTHERS (Specify) ___________________________
CABLE CAR
FUNICULAR
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PREPARED BY: ___________________________________________________________________________
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BOX 3
BOX 4
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DESIGN PROFESSIONAL, PLANS AND SPECIFICATIONS
SUPERVISOR / IN-CHARGE OF MECHANICAL WORKS
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PROFESSIONAL MECHANICAL ENGINEER
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_______________________________________________
MECHANICAL ENGINEER
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PROFESSIONAL MECHANICAL ENGINEER_______________________________________________
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(Seal and Signature Over Printed Name)(Seal and Signature Over Printed Name)
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Date ____________________Date ____________________
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ADDRESS
ADDRESS
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PRC NO.
VALIDITY
PRC NO.
VALIDITY
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PTR NO.
DATE ISSUED
PTR NO.
DATE ISSUED
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ISSUED AT
TIN
ISSUED AT
TIN
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BOX 5
BOX 6
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BUILDING OWNER
WITH MY CONSENT: LOT OWNER
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______________________________________________________________________________________________
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(Signature Over Printed Name)(Signature Over Printed Name)
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Date ____________________Date ____________________
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ADDRESS
ADDRESS
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CTC NO.
DATE ISSUED
PLACE ISSUED
CTC NO.
DATE ISSUED
PLACE ISSUED
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