DPWH ANCILLARY FORM NO.

2003-001-P
Republic of the Philippines
Department of Public Works & Highways
Pamahalaang Lungsod/Bayan

Kalakhang Maynila!Lalawigan
TANGGAPAN NG PINUNONG PANGGUSALI
(fficr of tlJr j/juilbing ffitial)
PROCESSING AND EVALUATION DIVISION
$ectiott
PLUMBING PERMIT
APPLICATION NO. PP NO. BUILDING PERMIT NO.
I I I I [l_I_I -1 I I II r.-1 -.-1 -.-1---r-1---r-1----rl--rl---.1
I I I I I I I I I I I
BOX 1 (TO BE ACCOMPLISHED BT THE OWNER/APPLI CANT)
OWNER/APPILCANT LAST NAME FIRST NAME M.l. TIN
FOR CONSTRUCTION OWNED FORM OWNEERSHIP USE OR CHARACTER OF OCCUPANCY
BY AN ENTERPRISE
-
ADDERSS NO., STREET, BARANGAY, CITY /MUNICIPALITY ZIP CODE TELEPHONE NO.
LOCATION OF CONSTRUCTION LOT NO. BLK. NO. TCT NO. TAX DEC. NO.
STREET BARANAGAY
- --- -
CITY/MUNICIPALITY OF
SCOPE OF WORK
0 NEW CONSTRUCTION 0 RENOVATION 0 DEMOLITION
0 ERECTION 0 CONVERSION 0 ACCESSORY BUILDING/STRUCTURE
0 ADDITIONAL 0 REP/\IH 0 OTHERS (specify)
0 ALTERATION 0 MOVI NG
'-..
- --
BOX 2(TO BE ACCOMPLISHED BY THE DESIGN PROFFESSIONAL)

FIXTURES TO BE INSTALLED
QTY. NEW EXISTING KIND
FIXTURES FIXTURES FIXTUHES
D D 0 WAIERCLOSET
D D 0 FLOOR DHAIN
D D D U\V/\TORY
D D 0 KIICIItN SINK
D 0 0 FI\UCE f
0 0 0 SHOWER
0 0 D WI\ fER METER
D 0 D GHI./\S[ f RAP
0 D 0 HlllH TUB
0 D 0 SlOP SINK
D D D URINI\1.
D D 0 1\IR CONDITIONING UNIT
D D D WIITER TANK/RESERVOIR
TOTAL
0 WATER DISTRIBUTION SYSTEM 0 SEWAGE SYSTEM
PREPARED BY: --- ----
-
BOX3
DESIGNE PROFESSIONAL, PlANS AND SPECIFICATION
MASTER PLUMER
(Signature Over Printed Name)
-
Address
PRC No. Validity
- --M----
--- -----
PTR No. Date Issued
Issued at TIN
'--
QTY. NEW EXISTING KIND OF
FIXTURES FIXTURES FIXTURES
D D D BIDEnl
D D D TRAYS
D D 0 DENTAL CUSPIDOR
D D 0 DRINKING WATER
D D 0 BAR SINK
D D 0 SODA FOUNTAIN SINK
D 0 0 LABOLATORY SINK
D D 0 STERILIZER
0 D D OTHERS (Specify)
D 0
D D
D 0
D D
TOTAL
0 SEPTICTANK 0 STORM DRAINAGE SYSTEM
BOX4
FULL-TIME INSPECTOR AND SUPERVISOR OF CONSTRUCTION WORK
MASTER PLUMER
(Signature Over Printed Name)
Address
PRC No. Validity
PTR No. Date Issued
Issued at TIN
'
/
BOX5 BOX6

BUILDING OWNER
WITH MY CONCERN: LOT OWNER
(Signature Over Printed Name)
(Signature Over Printed Name)
.. .
Address
Address
C.T.C. No. Date Issued Place Issued
C.T.C. No. Date Issued Place Issued
J .)
BOX 7 (SUBMITTALS TO BE RECEIVED, CHECKED AND RECORDED)
RECEIVED BY: I DATE:
FIVE (5) SETS OF PLUMBING DOCUMENTS
0 PLUMBING PLANS AND SPECIFICATIONS 0 COST ESTIMATES
0 BILL OF MATERIALS D OTHES (Specify)---------
BOX 8 (TO BE ACCOMPLISHED BY THE PLUMNING SECTION OF THE OFFICE OF THE BUILDING OFFICIAL) To be shown to the applicant.
I
REVIEWED:
PROGRESS FLOW
IN OUT
PROCESSED :--1 ACTION/REMARKS
CHIEF, PLUMBING SECTION
RECEIVING AND RECORDING
-
PLUMBING
OTHERS (Specify)
----
BOX 9 (TO BE ACCOMPLISHED BY THE PLUMBING SECTION OF THE OFFICE OF THE BUILDING OFFICIAL)
ASSESSED FEES
AMOUNT DUE ASSESSED BY O.R. NUMBEF DATE PAID REVIEWED BY:
FILING FEE
PROCESSING
OTHERS (Specify) CHIEF, PROCESSING AND EVALUATION
BOX10
ACTION TAKEN:
PERMIT IS HEREBY ISSUED SUBJECT TO THE FOLLOWING:
1. THAT THE DESIGNER IS AWARE THAT UNDER ARTICLl 1723 OF THE CIVIl CODE OF THE PHILIPPINES, HE/SHE IS RESPONSIBLE FOR DAMAGES IF IT SHOULD
COLLAPSE WITHIN FIFTEEN (15) YEARS FROM THE COMPLETION or THE BUILDING/STRUCTURE, IF DUE TO DEFECT IN THE PLANS OR SPECIFICATIONS OR
DEFECTS IN THE GROUND. HE/SHE IS THEREFORE ENJOINED TO CONDUCT PERIODIC INSPECTIONS OF THE BUILDING/STRUCTURE TO ENSURE THAT THE
CONDITIONS UNDER WHICH THE BUILDING/STRUCTURl WAS DESIGNED ARE NOT BEING VIOLATED OR ABUSED.
2. THAT THE PROPOSED PLUMBING WORKS SHALL BE IN ACCORDANCE WITH THE PLUMBING PLANS FILED WITH THIS OFFICE AND IN CONFORMITY WITH THE
REVISED PLUMBING CODE OF THE PHILIPPINES, THE CODE AND ITS IRR.
3. THAT UPON COMPLETION OF THE PLUMBING WORKS, THE LICENSED SUPERVISOR SHALL SUBMIT THE ENTRY TO THE LOGBOOK DULY SIGNED AND SEALED TO
THE BUILDING OFFICIAL INCLUDING AS-BUILD PLANS AND OTHER DOCUMENTS AND SHALL ALSO ACCOMPLISH THE CERTIFICATE OF COMPLETION STATING
THAT THE PLUMBING WORKS OF THE BUILDING CONFORM TO THE PROVISION OF THE REVISED PlUMBING CODE, THE CODE AND ITS IRR.
4. THAT THIS PERMIT IS NULl AND VOID UNLESS ACCOMPLISHED BY THE BUILDING PERMIT.
RECOMMENDING ISSUANCE OF PLUMBING PERMIT:
PERMIT ISSUED:
CHIEF, PLUMBING SECTION
(Signature Over Printed Name)
Date
---cHTEF, PROCESSING ANIHVAWATfON DIVISION
(Signature Over Printed Name)
Date _______ _

(Building Official)
Date
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