This is for DILG-DPWH-DICT-DTI JMC 2018-01

Republic of the Philippines Department of Public Works and Highways

City/Municipality of                                           Province of                                                             OFFICE OF THE BUILDING OF
UNIFIEDAPPLICATION FORM FOR BUILDING PERMIT AND FIRE SAFETY EVAL
CLEARANCE
NEW RENEWAL AMENDATORY
APPLICATION NO. AREA NO.

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

BOX 2 O
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OWNER/ APPLICANT LAST NAME FIRST NAME M.I. TIN

FOR CONSTRUCTION OWNED BY AN FORM OF OWNERSHIP

ENTERPRISE
ADDRESS: NO., STREET, BARANGAY, CITY/MUNICIPALITY ZIP CODE TELEPHONE NO.

LOCATION OF CONSTRUCTION: LOT NO.              BLK NO.              _ TCT NO.                           TAX DEC. NO.                                      
STREET                                       BARANGAY _                                               CITY/ MUNICIPALITY OF_                                                        
SCOPE OF WORK
NEW CONSTRUCTION RENOVATION                              RAISING                                                                 
ERECTION                            CONVERSION
                             ACCESSORY BUILDING/STRUCTURE                     
ADDITION                            REPAIR                                      OTHERS
(Specify)                                                    
ALTERATION                       
MOVING                                      

USE OR CHARACTER OF OCCUPANCY

GROUP A : RESIDENTIAL, DWELLINGS GROUP F : INDUSTRIAL OTHERS (Specify) _                             GROUP B
: RESIDENTIAL HOTEL, APARTMENT GROUP G : INDUSTRIAL STORAGE AND HAZARDOUS
GROUP C : EDUCATIONAL, RECREATIONAL GROUP H : RECREATIONAL, ASSEMBLY OCCUPANT LOAD LESS THAN 1000
GROUP D : INSTITUTIONAL GROUP I : RECREATIONAL, ASSEMBLY OCCUPANT LOAD 1000 OR MORE GROUP
E : BUSINESS AND MERCANTILE GROUP J : AGRICULTURAL, ACCESSORY

OCCUPANCY CLASSIFIED                                                                              TOTAL ESTIMATED COST P                                                                

NUMBER OF UNITS                                                                                        PROPOSED DATE OF CONSTRUCTION                                                
TOTAL FLOOR AREA                                                         SQUARE METERS EXPECTED DATE OF COMPLETION                                                    
LOT AREA                                                                         SQUARE METERS                                                                                        

FULL-TIME INSPECTOR AND SUPERVISOR OF CONSTRUCTION WORKS (REPRESENTING THE OWNER)

Address

ARCHITECT OR CIVIL ENGINEER

PRC No. Validity
(Signed and Sealed Over Printed Name)
Date                                                      
PTR No. Date Issued

Issued at TIN
BOX 3
BOX 4
APPLICANT: WITH MY CONSENT: LOT OWNER / AUTHORIZED REPRESEN
                                                                                           Date                                                                                                                  Date                  
(Signature Over Printed Name) (Signature Over Printed Name)

Address Address
CTC No Date Issued Place Issued CTC No Date Issued
BOX 5
REPUBLIC OF THE PHILIPPINES ) S.S CITY/MUNICIPALITY OF                                                                            )
BEFORE ME, at the City/Municipality of                                                                                                   , on                                               personally appeared the followi
APPLICANT
C.T.C. No. Date Issued Place Issued
LICENSED ARCHITECT OR CIVIL ENGINEER C.T.C. No. Date Issued Place Issued
(Full-Time Inspector and Supervisor of Construction Works)
whose signatures appear hereinabove, known to me to be the same persons who executed this standard prescribed form and acknowledged to me that the sam
free and voluntary act and deed.
WITNESS MY HAND AND SEAL on the date and place above written.
Doc. No.                
Page No.                
Book No.                 NOTARY PUBLIC (Until December                          )
Series of                

Copy 1: Owner Copy 2: OBO Copy 3: BFP Copy 4: Philippine Statistics Authority
THE BUILDING OFFICIAL
E SAFETY EVALUATION
 Validity

Date Issued

TIN

/ AUTHORIZED REPRESENTATIVE
                          Date                          
r Printed Name)

Place Issued

                             )
ersonally appeared the following:

knowledged to me that the same is their

ecember                          )
BOX 6 (TO BE ACCOMPPLISHED BY THE PROCESSING AND EVALUATION DIVISION)

ASSESSED FEES BASIS OF AMOUNT

ASSESSMENT DUE
 FILING FEE

 PROCESSING FEE

 LOCATIONAL / ZONING OF LAND

USE
 LINE AND GRADE (Geodetic)

 FENCING

 ARCHITECTURAL

 CIVIL / STRUCTURAL

 ELECTRICAL

 MECHANICAL

 SANITARY

 PLUMBING

 ELECTRONICS

 INTERIOR

 FIRE CODE CONSTRUCTION TAX

 SURCHARGES

 PENALTIES

TOTAL
TERMS AND CONDITIONS
1. The Owner/Permittee shall accomplish the prescribe Unified Application Form, with the assistance of the
concerned design professional/s and/or the Architect/Civil Engineer, hired/commissioned by the Owner/Permittee as
time inspector/supervisor of the construction works, by filling up the necessary data / information required thereat.
2. The fully accomplished prescribed Unified Application Form, duly notarized, shall be submitted to the concerned
Office of the Building Official accompanied by the various applicable ancillary and accessory permits, plans and
specifications signed and sealed by the corresponding design professionals who shall be responsible for the
comprehensive and correctness of the plans in compliance to the National Building Code (PD 1096), its IRR and to
applicable referral codes and professional regulatory laws, together with the other documentary
requirements pursuant to Section 302 of PD 1096 and its IRR.
ASSESSED BY
 with the assistance of the
ed by the Owner/Permittee as full-
formation required thereat.
e submitted to the concerned
ssory permits, plans and
be responsible for the
de (PD 1096), its IRR and to all
r documentary