RUSTY ETRATA's HERO SARI-SARI STORE

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Business Permit Requirements:

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Sanitary 
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ANNEX 1 (Page 1 of 2)
APPLICATION FORM FOR BUSINESS PERMIT
TAX YEAR 2019
MUNICIPALITY OF BENITO SOLIVEN
INSTRUCTIONS:
1. Provide accurate informa on and print legibly to avoid delays. Incomplete applica on form will be returned to the
applicant.
2. Ensure that all documents a ached to this form (if any) are complete and properly filled out.

I. APPLICANT SECTION
1. BASIC INFORMATION
[✓] New [] Renewal Mode of Payment: [✓] Annually [] Semi-Annually [] Quarterly
Date of Applica on: 2019-12-12 DTI/SEC/CDA Registra on No. : 23456
TIN : 091-230-435-903 DTI/SEC/CDA Registra on Date : 2019-12-12
Type of Business : [✓] Single [] [] Corpora on [] Coopera ve
Partnership
Amendment: From [] Single [] [] Corpora on
Partnership
To [] Single []
Partnership [] Corpora on
Are you enjoying tax incen ve from any Government En ty? [] Yes [✓] No. Please specify the en ty?
Name of Taxpayer / Registrant
Last Name: ETRATA First Name: RUSTY Middle Name:
Business Name: HERO SARI-SARI STORE
Trade name / Franchise:
2. OTHER INFORMATION
Note: For renewal applica ons, do not fill up this sec on unless certain informa on have changed.
Business Address: ,, ,, , District II (Pob.), Benito Soliven, Isabela

Postal Code: 3331 Email Address: etrata_rusy@yahoo.com

Telephone No.: n/a Mobile No.: 09613166797
Owner’s Address: , , , , , District II (Pob.), Benito Soliven, Isabela

Postal Code: 3331 Email Address: etrata_rusty@yahoo.com

Telephone No.: n/a Mobile No.: 09613161797
In case of emergency, provide name of contact person:
Telephone/Mobile No.: Email Address:
Business Area (in sq m.): 25.00 Total No. of Employees in Establishment: 3 No. of Employees Residing within LGU:0

Note: Fill Up Only If Business Place is Rented

Lessor’s Full Name:
Lessor’s Full Address:
Lessor’s Full Telephone/Mobile No.:
Lessor’s Email Address:
Monthly Rental:
3. BUSINESS ACTIVITY
Capitaliza on Gross/Sales Receipts (for Renewal)
Line of Business No. of Units
(for New Business) Essen al Non-Essen al
Retail selling in sari-sari 0 500,000.00 0.00 0.00
stores
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 here.
I DECLARE UNDER PENALTY OF PERJURY that the foregoing informa on are true based on my personal knowledge and authen c
records. Further, I agree to comply with the regulatory requirement and other deficiencies within 30 days from release of the
permit.

SIGNATURE OF APPLICANT/TAXPAYER OVER PRINTED NAME

POSITION /TITLE

ANNEX 1 (Page 2 of 2) Applica on Form for Business Permit

II. LGU SECTION (Do Not Fill Up This Sec on)
1. VERIFICATION OF DOCUMENTS
Descrip on Office/Agency Yes No Not Needed
Occupancy Permit (For New) Office of the Building Official
Barangay Clearance (For Renewal) Barangay
Sanitary Permit/Health Clearance City Health Office
City Environmental Cer ficate City Environment and Natural Resources Office
Market Clearance (For Stall Holders) Office of the City Market Administrator
Valid Fire Safety Inspec on Cer ficate Bureau of Fire Protec on

Verified by: BPLO

2. ASSESSMENT OF APPLICABLE FEES

Local Taxes Amount Due Penalty/Surcharge Total
Business Tax 250.00 0.00 250.00
Filling fee 150.00 0.00 150.00
Business Plate Fee 350.00 0.00 350.00
Zoning Clearance 75.00 0.00 75.00
Occupa onal Fee 150.00 0.00 150.00
Garbage fees 450.00 0.00 450.00
Sanitary & Inspec on fee 350.00 0.00 350.00
Mayors Permit Fee 800.00 0.00 800.00
TOTAL FEES for LGU 2,575.00
FIRE SAFETY INSPECTION FEE

Assessed by: MTO FSIF Assessment Approved by: BFP

____________________ _________________________________

III. CITY/MUNICIPALITY FIRE STATION SECTION

DATE :
APPLICATION NO. :
(TO BE FILLED UP BY APPLICANT/OWNER)

Name of Applicant/Owner:
Name of Business:
Total Floor Area: Contact No.:
Address of Establishment:

Signature of Applicant/Owner
Cer fied by:
Customer Rela ons Officer FIRE SAFETY
Time and Date Received: INSPECTION  
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