Republic of the Philippines
NBC FORM NO. A-07 Municipality of Culion
Province of Palawan
OFFICE OF THE BUILDING OFFICIAL
ELECTRONICS PERMIT
APPLICATION NO. ELP No. BUILDING PERMIT NO.
BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE APPLICANT)
OWNER/APPLICANT LAST NAME FIRST NAME M.I TIN
FOR CONSTRUCTION OWNED FORM OF OWNERSHIP USE OR CHARACTER OF OCCUPANCY
BY AN ENTERPRISE
ADDRESS: NO. STREET BARANGAY
MUNICIPALITY ZIP CODE CONTACT NO./EMAIL ADDRESS
CULION 5315
LOCATION OF CONSTRUCTION: LOT NO. BLK NO. TCT NO. TAX DEC. NO.
STREET
STREET _________________________________________
BARANGAY BARANGAY __________________________MUNICIPALITY
CITY BAGUIO. .
SCOPE OF WORK
NEW INSTALATION ANNUAL INSPECTION OTHERS (Specify)
BOX 2 (TO BE ACCOMPLISHED BY THE DESIGN PROFESSIONAL)
NATURE OF INSTALLATION WORKS/EQUIPMENT SYSTEM:
□ TELECOMMUNICATION SYSTEM □ ELECTRONICS FIRE ALARM SYSTEM □ ELECTRONICS COMPUTERIZED PROCESS
CONTROLS AUTOMATION SYSTEM
□ BROADCASTING SYSTEM □ SOUND COMMUNICATION SYSTEM
□ BUILDING AUTOMATION MANAGEMENT AND
□ TELEVISION SYSTEM □ CENTRALIZED CLOCK SYSTEM CONTROL SYSTEM
□ INFORMATION TECHNOLOGY SYSTEM □ SOUND SYSTEM □ BUILDING WIRING UTILIZING COPPER CABLE
FIBER OPTIC CABLE OR OTHER MEDIAL
□ SECURITY AND ALARM SYSTEM □ ELECTRONICS CONTROL AND CONVEYOR SYSTEM ELECTRONICS SYSTEM
□ ANY OTHER ELECTRONICS AND I.T SYSTEMS, EQUIPMENT, APPARATUS, DEVICE AND/OR COMPONENT (Specify)
PREPARED BY:
BOX 3 BOX 4
DESIGN PROFESSIONAL, PLANS AND SPECIFICATION FULL-TIME INSPECTOR AND SUPERVISOR OF CONSTRUCTION WORKS
__________________________________ Date:_____________ __________________________________ Date:_____________
PROFESSIONAL ELECTRONICS ENGINEER ELECTRONICS ENGINEER
(Signed and Sealed Over Printed name) (Signed and Sealed Over Printed name)
Address Address
PRC. No. Validity PRC. No. Validity
PTR No. Date Issued PTR No. Date Issued
Issued at TIN Issued at TIN
BOX 5 BOX 6
BUILDING OWNER WITH MY CONSENT: LOT OWNER
______________________________________________ ______________________________________________
(Signature over Printed name) (Signature over Printed name)
Date:___________________ Date:___________________
Address Address
C.T.C. No. Date Issued Place Issued C.T.C. No. Date Issued Place Issued
TO BE ACCOMPLISHED BY THE PROCESSING AND EVALUATION DIVISION
BOX 7
RECEIVED BY: DATE:
FIVE (5) SETS OF ELECTRONICS DOCUMENTS
□ELECTRONICS PLAN AND SPECIFICATIONS □ COST ESTIMATE
□BILL OF MATERIALS □OTHERS (Specify)
BOX 8
PROGRESS FLOW
IN OUT PROCESSED BY
DATE TIME DATE TIME
ELECTRONICS
OTHERS (Specify)
BOX 9
ACTION TAKEN:
PERMIT IS HEREBY ISSUED SUBJECT TO THE FOLLOWING:
1. That the proposed electronics works shall be in accordance with the electronics plans filed with this Office and in
conformity with the latest Electronics Code of the Philippines, the National Building Code and its IRR.
2. That prior to any electronics installation, a duly accomplished prescribed “Notice of Construction” shall be submitted to
the Office of the Building Official.
3. That upon completion of the electronics works, the licensed supervisor/in-charged shall submit the entry to the logbook
duly signed and sealed to the building official including as-built plans and other documents and shall also accomplish the
Certificate of Completion stating that the electronic works conform to the provision of the Electronics Code of the
Philippines, the National Building Code and its IRR.
4. That this permit is null and void unless accompanied by the building permit.
PERMIT ISSUED BY:
ENGR. CHRISTIE D. FRUCTUOSO
BUILDING OFFICIAL
(Signature Over Printed Name)
Date _________________
