ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACAD
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FORM NO. 77-001-S
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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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APPLICATION NO.
ELECTRICAL PERMIT NO.
BUILDING PERMIT NO.
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ELECTRICAL PERMIT
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BOX 1 (TO BE ACCOMPLISHED PRINT BY THE OWNER/APPLICANT AND/OR LICENSED DESIGN PROFESSIONAL )
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OWNER/APPLICANT
LAST NAME
FIRST NAME
M.I.
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
TEL. 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 INSTALLATION
RECONNECTION OF SERVICE ENTRANCE
RELOCATION OF SERVICE CAPACITY
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ANNUAL INSPECTION
SEPARATION OF SERVICE ENTRANCE
OTHERS (SPECIFY) ____________________
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TEMPORARY
UPGRADING OF SERVICE ENTRANCE
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SUMMARY OF ELECTRICAL LOADS/CAPACITIES
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TOTAL CONNECTED LOADTOTAL TRANSFORMER CAPACITYTOTAL GENERATOR/UPS CAPACITY
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________________ KVA________________ KVA________________ KVA
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BOX 2 ( TO BE ACCOMPLISHED IN PRINT BY THE DESIGN PROFESSIONAL )
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DESIGN PROFESSIONAL, PLANS AND SPECIFICATIONS
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__________________________________________
ADDRESS
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PROFESSIONAL ELECTRICAL ENGINEER
PRC NO.
VALIDITY
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(SIGNED AND SEALED OVER PRINTED NAME)
PTR NO.
DATE ISSUED
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ISSUED AT
TIN
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BOX 3
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SUPERVISOR OF ELECTRICAL WORKS
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PROFESSIONAL ELECTRICAL ENGINEER
REGISTERED ELECTRICAL ENGINEER
REGISTERED MASTER ELECTRICIAN
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(Signature Over Printed Name)
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ADDRESS
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PRC NO.
VALIDITY
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PTR NO.
DATE ISSUED
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ISSUED AT
TIN
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BOX 4
BOX 5
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BUILDING OWNER/APPLICANT
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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ADDRESS
ADDRESS
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C.T.C. NO.
DATE ISSUED
PLACE ISSUED
C.T.C. NO.
DATE ISSUED
PLACE ISSUED
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