Republic of the Philippines

OFFICE OF THE BUILDING OFFICIAL

Lucena City

SANITARY / PLUMBING PERMIT

APPLICATION NO. PERMIT NO.

_______________________ _________________________
_______________________ _________________________
Date of Application Date Issued

Box 1 (TO BE ACCOMPLISHED BY SANITARY ENGINEER / MASTER PLUMBER, IN PRINT)

NAME OF APPLICANT LAST NAME FIRST NAME M.I. TAX ACCT. NO.

ADDRESS NO. OF STREET/BARANGAY/CITY/MUNICIPALITY

LOCATION OF THE INSTALLATION NO. OF STREET/BARANGAY/CITY/MUNICIPALITY

SCOPE OF WORK Addition of ________________________ OTHERS (specify)

Repair of __________________________ __________________________________
New Installation Removal of ________________________ __________________________________
_
USE OR TYPE OF OCCUPANCY

Residential ___________________________ Agricultural ___________________________

Commercial ___________________________ Parks, Plaza & Monuments __________________
Industrial ___________________________ Recreational ___________________________
Institutional ___________________________ Others (specify) ___________________________

FIXTURES TO BE INSTALLED :

Qty. New Existing Kind of Fixtures Qty. New Existing Kind of Fixtures
( ) ( ) ( ) Water Closet ( ) ( ) ( ) Bidette
( ) ( ) ( ) Floor Drain ( ) ( ) ( ) Laundry Trays
( ) ( ) ( ) Lavatories ( ) ( ) ( ) Dental Cuspidor
( ) ( ) ( ) Faucets ( ) ( ) ( ) Gas Heater
( ) ( ) ( ) Kitchen Sink ( ) ( ) ( ) Elec. Heater
( ) ( ) ( ) Shower Head ( ) ( ) ( ) Water Boiler
( ) ( ) ( ) Water Meter ( ) ( ) ( ) Drinking Fountain
( ) ( ) ( ) Grease Trap ( ) ( ) ( ) Bar Sink
( ) ( ) ( ) Bath Tubs ( ) ( ) ( ) Soda Fountain
( ) ( ) ( ) Slop Sink ( ) ( ) ( ) Sink
( ) ( ) ( ) Urinal ( ) ( ) ( ) Lavatory Sink
( ) ( ) ( ) Air Conditioning Unit ( ) ( ) ( ) Sterlizer
( ) ( ) ( ) Water Tank ( ) ( ) ( ) Swimming Pool
( ) ( ) ( ) Reservoir ( ) ( ) ( ) Others (specify)

_______ Water Distribution System ____________ Sanitary System __________ Storm Drainage System

WATER SUPPLY :

Shallow Well System Disposal Surface Drainage

Deep Well & Pump Set Waste Water Treatment Plant Street Canal
City/Municipality Water System Septic Vault/Imhoof Tank Water Course
Others ____________________ Sanitary Sewer Connection

Number of Storey of Building Total Area of Building / Subdivision

________________________ ________________________sq.m.
Disposal Date ____________ Total Cost of Installation
Start of Installation ________ ____________________________
Expected Date of Completion Prepared by :
________________________ ____________________________
Box 2 (TO BE ACCOMPLISHED BY THE RECEIVING & RECORD SECTOR)

SANITARY PLUMBING PLANS & SPECIFICATION BUILDING DOCUMENTS

BILL OF MATERIALS COST ESTIMATES
OTHERS (SPECIFY)