ABCDEFGHIJKLMNOPQRSTUVWXYZ
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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.
PERMIT NO.
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SANITARY/PLUMBING PERMIT
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DATE OF APPLICATIONDATE ISSUED
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BOX 1 (TO BE ACCOMPLISHED PRINT BY THE OWNER/APPLICANT)
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OWNER/APPLICANT
LAST NAME
FIRST NAME
M.I.
TIN
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ADDRESS:
NO.
STREET
BARANGAY
CITY/MUNICIPALITY
TEL. NO.
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LOCATION OF INSTALLATION:
NO.
STREET
BARANGAY
CITY/MUNICIPALITY
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SCOPE OF WORK
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NEW INSTALLATION
ADDITION OF __________________
OTHERS (SPECIFY)
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REPAIR OF ____________________
_______________ OF _______________
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REMOVAL OF __________________
_______________ OF _______________
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USE OF TYPE OF OCCUPANCY
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RESIDENTIAL
__________________________
AGRICULTURAL
__________________________
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COMMERCIAL
__________________________
PARKS, PLAZAS, MONUMENTS
__________________________
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INDUSTRIAL
__________________________
RECREATIONAL
__________________________
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INSTITUTIONAL
__________________________
OTHERS (SPECIFY)
__________________________
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FIXTURES TO BE INSTALLED:
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QTYNEW FIXTURESEXISTING FIXTURESKIND OF FIXTURESQTYNEW FIXTURESEXISTING FIXTURESKIND OF FIXTURES
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WATER CLOSETBIDET
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FLOOR DRAINLAUNDRY TRAYS
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LAVATORIESDENTAL CUSPIDOR
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KITCHEN SINKGAS HEATER
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FAUCETELECTRIC HEATER
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SHOWER HEADWATER BOILER
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WATER METERDRINKING FOUNTAIN
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GREASE TRAPBAR SINK
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BATH TUBSSODA FOUNTAIN SINK
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SLOP SINKLABORATORY SINK
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URINALSTERILIZER
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AIR CONDITIONING UNITSWIMMING POOL
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WATER TANK/RESERVOIROTHERS (SPECIFY) _______________
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TOTAL
TOTAL
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WATER DISTRIBUTION SYSTEM
SANITARY SEWER SYSTEM
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STORM DRAINAGE SYSTEM
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WATER SUPPLY
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SHALLOW WELL
WASTE WATER TREATMENT PLANT
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DEEP WELL & PUMP SET
SEPTIC VAULT/IMF OFF TANK
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CITY/MUNICIPAL WATER SYSTEM
SANITARY SEWER CONNECTION
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SURFACE DRAINAGE
SUB-SURFACE SAND FILTER
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STREET CANAL
WATER COURSE
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OTHERS __________________________
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NUMBER OF STOREYS OF BUILDING
TOTAL AREA OF BUILDING/SUBDIVISION
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_____________________
SQ.M.
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PROPOSED DATE
TOTAL COST
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START OF INSTALLATION _____________________
OF INSTALLATION _________________________________
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EXPECTED DATE
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OF COMPLETION ____________________________
PREPARED BY _____________________________________
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BOX 2 (TO BE ACCOMPLISHED BY BUILDING OFFICIAL)
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ACTION TAKEN
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PERMIT IS HEREBY GRANTED TO INSTALL THE SANITARY/PLUMBING FIXTURES ENUMERATED HEREIN SUBJECT TO THE FOLLOWING CONDITIONS:
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1.THAT THE PROPOSED INSTALLATION SHALL BE IN ACCORDANCE WITH APPROVED PLANS FILED WITH THIS OFFICE AND IN CONFORMITY WITH THE NATIONAL BUILDING CODE.
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2.THAT A DULY LICENSED SANITARY ENGINEER/MASTER PLUMBER BE ENGAGE TO UNDERTAKE THE INSTALLATION/CONSTRUCTION.
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ENGR. EDUARDO G. VILLAGRACIA
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3.THAT A CERTIFICATE OF COMPLETION DULY SIGNED BY A SANITARY ENGINEER/MASTER PLUMBER IN CHARGE OF INSTALLATION SHALL BE SUBMITTED NOT LATER THAN SEVEN (7) DAYS AFTER COMPLETION OF THE INSTALLATION.ENGINEER III (SO No. 003 - 24)
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