DPWH FORM NO.

95-002-E
Republic of the Philippines
Department of Public Works and Highways
Office of the Building Official

City of Bacoor
Province of Cavite
AREA CODE 04119

APPLICATION NO. DATE APPLICATION FILED:

123456789 12-10-2023
APPLICATION FOR ELECTRICAL PERMIT
02-12-2024 (Accomplished in Print and in Duplicate) 03-01-2024
Date of Proposed Start of Installation Expected Date of Completion

BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE APPLICANT)

NAME OF OWNER / APPLICANT: Gwyneth LASTNAME: Santos FIRSTNAME: Gwyneth MIDDLE NAME: N/a TIN:

ADDRESS: NO. STREET BARANGAY CITY/MUNICIPALITY TELEPHONE NO.

LOCATION OF INSTALLATION: BLK LOT NO. STREET SUBDIVISION / BARANGAY

BACOOR CITY, CAVITE

SCOPE OF WORK

NEW INSTALLATION ADDITION OF OTHERS (SPECIFY)

ANNUAL INSPECTION REPAIR OF
REMOVAL OF

TYPE OF OCCUPANCY OR USE

A. RESIDENTIAL DWELLING E. BUSINESS & MERCHANTILE I. ASSEMBLY OCCUPANCY LOAD 1000 OR MORE

B. RESIDENTIAL, HOTEL, APARTMENT F. INDUSTRIAL J. ACCESORY

C. EDUCATIONAL & RECREATION G. STORAGE K. OTHERS (SPECIFY)

D. INSTITUTIONAL H. ASSEMBLY OTHER THAN GROUP 1

NUMBER OF OUTLETS NUMBER OF EQUIPMENT / WIRING DEVICES
LIGHT SPO, COOKING UNIT TOGGLE SWITCH FA DETECTORS
CONVENIENCE / RECEPTABLE SPO, WATER HEATER BELLS / BUZZER OTHERS (see attached list)
SPO, AIRCON SPO, WATER PUMP PUSH BUTTONS

BOX 2 (PROFESSIONAL ELECTRICAL ENGINEER WHO SIGNED AND SEALED PLANS & SPECIFICATIONS)
NAME PRC REG. NO. VALIDITY

ADDRESS TELEPHONE NO.

PTR NO. DATE ISSUED PLACE ISSUED

SIGNATURE DATE SIGNED TIN

BOX 3 (ELECTRICAL CONTRACTOR – 200 AMPERE MAIN AND ABOVE)

NAME PCAB LIC. NO. (SPECIALTY ELECTRICAL)
VALIDITY
ADDRESS TELEPHONE NO.

SIGNATURE DATE SIGNED

BOX 4 (PERSON-IN-CHARGE OF INSTALLATION)

PROFESSIONAL ELECTRICAL ENGINEER REGISTERED ELECTRICAL ENGINEER REGISTERED MASTER ELECTRICIAN

(NOT EXCEEDING 600 VOLTS & 500KVA)
NAME PRC REG. NO. VALIDITY

ADDRESS TELEPHONE NO.

PTR NO. DATE ISSUED PLACE ISSUED

SIGNATURE DATE SIGNED TIN

BOX 5 (TO BE ACCOMPLISHED BY THE APPLICANT)

NAME SIGNATURE TIN
CTC NO.
DATE ISSUED
PLACE ISSUED

BOX 6 (TO BE RECEIVED BY RECEIVING / RECORDING SECTION)

RECEIVED BY:
ELECTRICAL PLANS & SPECIFICATIONS (5 SETS) SIGNATURE OVER PRINTED NAME

DATE RECEIVED:
DPWH FORM NO. 95-002-E
Republic of the Philippines

Department of Public Works and Highways

Office of the Building Official

City of Bacoor
Province of Cavite
AREA CODE 04119

PERMIT NO. APPLICATION NO.

DATE ISSUED
DATE FILLED
PAID UNDER O.R. NO.
AMOUNT
DATE

ELECTRICAL PERMIT

BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE APPLICANT)

NAME OF OWNER / APPLICANT: LAST NAME FIRST NAME MIDDLE NAME TIN

ADDRESS: NO. STREET BARANGAY CITY/MUNICIPALITY TELEPHONENO.

LOCATION OF INSTALLATION: BLK LOT NO. STREET SUBDIVISION / BARANGAY

BACOOR CITY, CAVITE

BOX 2 (TO BE ACCOMPLISHED BY THE DIVISION / SECTION CONCERNED)

ASSESED FEES
AMOUNT DUE ASSESED BY O.R. NO. DATE PAID

REVIEWED

CHIEF, PROCESSING DIV/SEC

BOX 3 (TO BE ACCOMPLISHED BY THE DIVISION / SECTION CONCERNED)

ACTION TAKEN:

PERMIT IS HEREBY GRANTED TO INSTALL THE ELECTRICAL W IRING, DEVICES AND EQUIPMENT ENUMERATED IN THE APPLICANT ION SUBJECT TO
THE FOLLOWING CONDITIONS.

1. THAT THE PROPOSED INSTALLATIONS BE IN ACCORDANCE WITH THE APPROVED PLANS FILED WITH THIS OFFICE AND IN CONFORMITY WITH THE
PROVISIONS OF THE LATEST EDITION OF THE PHILIPPINE ELECTRICAL CODE.

2. THAT A DULY LICENSED ELECTRICAL PRACTITIONER BE INCHARGDE OF THE INSTALLATION / CONSTRUCTION.

3. THAT A CERIFICATE OF COMPLETION DULY SIGNED BY THE ELECTRICAL PRATIOTIONER INCHARGE OF THE INSTALLATION BE SUBMITTED
NOT LATER THAN A SEVEN (7) DAYS AFTER COMPLETION OF THE INSTALLATION.

4. THAT A CERTIFICATE OF FINAL ELECTRICAL INSPECTION BE SECURED PRIOR TO THE ACTUAL OCCUPANCY OF THE BUILDING

5. THIS PERMIT SHALL BE POSTED AT THE DOOR OR SITE OF WORK.

RECOMMENDING APPROVAL:

ENGR. RODERICK C. JAVINAL / ENGR. BERNARDO L. MANALILI

ENGINEER II

APPROVED BY:

ENGR. FELICITO R. MEJIA

CITY BUILDING OFFICIAL

NOTE 1: This permit may be cancelled or revoked pursuant to Section 305 & 306 of the National Building Code
NOTE 2: Alterations on this form are not allowed