MPW FORM NO.
: 77-009-B REPUBLIC OF THE PHILIPPINES
MINISTRY OF PUBLIC WORKS
CITY OF SAN JOSE DEL MONTE
OFFICE OF THE CITY BUILDING OFFICIAL
APPLICATION NO: PERMIT NO:
DISTRICT / CITY/ MUNICIPALITY
AREA CODE: 1420R
DATE OF APPLICATION FENCING PERMIT DATE ISSUED
BOX 1 ( TO BE ACCOMPLISHED BY APPLICANT IN PRINT )
LAST NAME FIRSTNAME MI TAX ACCT. NO.
NAME OF APPLICANT
FOR CONSTRUCTION OWNED FORM OF OWNERSHP
BY AN ENTERPRISE
ADDRES NO. STREET BARANGAY CITY/ MUNICIPALITY TEL. NO.:
LOCATION OF AREA NO.: STREET BARANGAY CITY/ MUNICIPALITY
TO BE FENCED
SCOPE OF WORK: ADDITION RENOVATION
NEW FENCE REPAIR OTHERS ( SPECIFY )
BOX 2 ( TO BE ACCOMPLISHED BY THE RECEIVING & RECORDING SECTION )
ACCOMPANYING DOCUMENTS
XEROX COPY OF T.C.T.
XEROX COPY OF LOT / SITE PLAN
XEROX COPY OF LATEST LAND TAX RECEIPT
XEROX COPY OF CONTRACT OF LEASE ( IF NOT OWNED BY APPLICANT )
OTHER CLEARANCES ( SPECIFY )
BOX 3 ( TO BE ACCOMPLISHED BY DESIGNING ARCHITECT / CIVIL ENGINEER / CONTRACTOR IN PRINT )
LENGTH IN METERS HEIGHT IN METERS
MEASUREMENTS
TYPE OF FENCING INDEGENOUS MATERIALS RC & INTERLINK / CYCLONE WIRE
RC ( REINORCED CONCRETE ) RC & STEEL MATTING
RC & CONCRETE HOLLOW BLOCKS RC & BARB WIRE & OTHER WIRES
RE & BRICKS OTHERS ( SPECIFY )
BOX 4 ( TO BE ACCOMPLISHED BY THE BUILDING OFFICIAL )
ACTION TAKEN
PERMIT IS HEREBY GRANTED SUBJECT TO THE FOLLOWING CONDITIONS:
1 THAT THE PROPOSED CONSTRUCTION / ADDITION / REPAIR / RENOVATION SHALL BE IN
CONFORMITY WITH THE NATIONAL BUILDING CODE ( PD 1096 ) AND ITS CORRESPONDING
IMPLEMENTING RULES AND REGULATIONS.
2 THAT THE REQUIRED SETBACK SHALL BE OBSERVED.
ARCH. PAVEL D. HALOG
BUILDING OFFICIAL
DATE
NOTE: THIS PERMIT MAY BE CANCELLED OR REVOKED PURSUANT TO
SECTIONS 305 AND 30 OF THE NATIONAL BUILDING CODE
______1420 R________
BOX 5 ( TO BE ACCOMPLISHED BY THE DIVISION CONCERNED )
ASSESSED FEES
AMOUNT DUE ASSESSED BY O.R. NUMBER DATE PAID
LINE & GRADE
FENCING
ELECTRICAL ( IF ANY )
OTHERS ( SPECIFY )
TOTAL REVIEWED ( CHIEF PROCESSING DIVISION )
BOX 6 ( TO BE ACCOMPLISHED BY DIVISION / SECTION CONCERNED )
PROGRESS FLOW
IN OUT ACTION / REMARKS PROCESSED BY
NOTED TIME DATE TIME DATE
CHIEF, PROCESSING DIV.
RECEIVING & RECORDING
GEODETIC LINE CONFORMITY
STRUCTURAL
ELECTRICAL
CASHIER
WE HEREBY AFFIX OUR HANDS SIGNIFYING OUR CONFORMITY TO THE INFORMATION
HEREIN ABOVE SET FORTH
BOX 7 BOX 8
ARCHITECT/ CIVIL ENGINEER PRC REG. NO.: APPLICANT
SIGNED & SEALED PLANS & SPECIFICATIONS
PRINT NAME:
PRINT NAME:
ADDRESS: SIGNATURE:
PTR NO.: DATE ISSUED: PLACE ISSUED: RES. CERT. NO. DATE ISSUED PLACE OF ISSUE
SIGNATURE: TIN:
BOX 9 BOX 10
ARCHITECT/ CIVIL ENGINEER PRC REG. NO.: CONSENT OF LAND OWNER
IN-CHARGE OF CONSTRUCTION PRINT NAME OF LAND OWNER
PRINT NAME:
ADDRESS:
ADDRESS: OCT. TCT NO.: TAX DECLARATION NO.:
PTR NO.: DATE ISSUED: PLACE ISSUED: RES. CERT. NO. DATE ISSUED PLACE OF ISSUE
SIGNATURE: TIN: SIGNATURE: TIN:
AFP - 09-0651 FP - 09-0041
August 19, 2009
ENGR. RUFINO A. GRAVADOR JR.
City Engineer
P 416.00 RAGJR/JCQ 116624 8/19/2009
INS. FEE P
416.00
