REPUBLIC OF THE PHILIPPINES DPWH FORM NO.

77-001-E
ANGELES CITY Revision No. 01
OFFICE OF THE BUILDING OFFICIAL

APPLICATION NO. APPLICATION FOR DATE APPLICATION FILED

ELECTRICAL PERMIT

______________________________ ________________________________
Date of Proposed Start of Installation Expected Date of Completion

Box 1 (TO BE ACCOMPLISHED BY A DULY QUALIFIED ELECTRICAL PRACTITIONER)

NAME OF OWNER/APPLICANT LAST NAME FIRST NAME MIDDLE NAME T.I.N

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

LOCATION OF INSTALLATION: NO. STREET BARANGAY CITY/MUNICIPALITY

SCOPE OF WORK: ADDITION OF OTHERS (SPECIFY)

NEW INSTALLATION REPAIR OF
ANNUAL INSPECTION REMOVAL OF

TYPE OF OCCUPANCY:
A. RESIDENTIAL DWELLING H. BUSINESS AND MERCANTILE E. ASSEMBLY OCCUPANT LOAD 1000 OR MORE
B. RESIDENTIAL , HOTEL, APARTMENT I. INDUSTRIAL F. ACCESSORY
C. EDUCATION AND RECREATION J. STORAGE AND HAZARDOUS G. OTHERS (SPECIFY)
D. INSTITUTIONAL K. ASSEMBLY OTHER THAN GROUP I

NUMBER OF OUTLETS: NUMBER OF EQUIPMENT/WIRING DEVICES:

LIGHT SPO, COOKING UNIT TOGGLE SWITCH FA DETECTOR
CONVENIENCE/RECEPTACLE SPO, WATER HEATER BELL/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 TEL./FAX NO.

P.T.R NO. DATE ISSUED PLACE ISSUED

SIGNATURE DATE ISSUED T.I.N

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

NAME PCAB LIC. NO. (SPECIAL ELECTRICAL)

ADDRESS TEL. FAX. NO.

BOX 4 (PERSON IN-CHARGE OF INSTALLATION)

PROFESSIONAL ELECTRICAL ENGINEER REGISTERED ELECTRICAL ENGINEER REGISTERED MASTER ELECTRICIAN
(Not Exceeding 600Volts & 500kVA)
NAME PRC REG NO. VALIDITY

ADDRESS TEL/FAX NO.

P.T.R NO. DATE ISSUED PLACE ISSUED

SIGNATURE DATE SIGNED T.I.N

BOX 5 (OWNER/AUTHORIZED REPRESENTATIVE)

NAME SIGNATURE T.I.N
CTC NO.
DATE ISSUED
PLACE ISSUED

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

ELECTRICAL PLANS AND SPECIFICATIONS (5 SETS)

RECEIVED BY:
Signature Over Printed Name

DATE RECEIVED:
 DPWH FORM NO. 77-002-E
Revision No. 00

PERMIT NO. APPLICATION NO.

DATE ISSUED _________________________________

PAID UNDER O.R NO. Date Filed
AMOUNT
DATE

ELECTRICAL PERMIT
(To be Accomplished by the Office Concerned)

BOX 1
NAME OF OWNER/APPLICANT LAST NAME FIRST NAME MIDDLE NAME T.I.N

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

LOCATION OF INSTALLATION: NO. STREET BARANGAY CITY/MUNICIPALITY

BOX 2

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

REVIEWED BY:

CHIEF, PROCESSING DIV./SEC.

BOX 3

PERMIT IS HEREBY GRANTED TO INSTALL THE ELECTRICAL WIRING, DEVICES AND EQUIPMENT ENUMERATED IN THE APPLICATION
SUBJECT TO THE FOLLOWING CONDITIONS:

THAT THE PROPOSED INSTALLATION BE IN ACCORDANCE WITH THE APPROVED PLANS WITH THIS OFFICE AND IN CONFORMITY
WITH THE PROVISIONS OF THE LATEST EDITION OF THE PHILIPPINE ELCTRICAL CODE.
THAT A DULY LICENSED ELECTRICAL PRACTITIONER BE INCHARGE OF THE INSTALLATION/CONSTRUCTION.
THAT A CERTIFICATE OF COMPLETION DULY SIGNED BY THE ELECTRICAL PRACTITIONER INCHARGE OF THE INSTALLATION BE SUBMITTED
NOT LATER THAN SEVEN (7) DAYS COMPLETION OF INSTALLATION.
THAT A CERTIFICATE OF FINAL ELECTRICAL INSPECTIONS BE SECURED PRIOR TO THE ACTUAL OCCUPANCY OF THE BUILDING.
THIS PERMIT SHALL BE POSTED AT THE DOOR OR SITE OF WORK.

APPROVED BY:

ENGR. GIOVANNI L. AQUINO

ELECTRICAL ENGINEER OF THE BUILDING OFFICE Date

(Signature over Printed Name)

4252-2026
PRC REG. NO. & VALIDITY Date

Noted:

BUILDING OFFICIAL
(Signature over Printed Name)

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