DPWH ANCILLARY FORM NO 2003-001-S

APPLICATION NO.
Republic of the Philippines
Depa11ment of Publ ic Works & Highways
Pamahalaang Lungsod/Bayan no-"- ----
Kalakhang Maynila/ Lalawigan no-a ___ ____ _
TANGGAPAN NG PINUNONG PANGGUSALJ
(fficr of tlJr JJuilbing C!&ffiti al)
PROCESSING AND EVALUATION DIVISION

SANITARY PERMIT
sr NO. BUILDI NG PERMIT NO.
r I I I I I I I [JJ
I l-lr---r-1 -.I ---.1 --r l ---.1--. 1____,1,---,1
I I I I I I I I [Tl
BOX 1 (TO BE ACCOMPLISHED BT THE OWNER/APPLI CANT)
OWNER/APPILCANT LAST NAME FIRST NAME M.L TI N
FOR CONSTRUCTION OWNED FORM OWNEERSHIP USE OR CHARACTER OF OCCUPANCY
BY AN ENTERPRISE
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ADDERSS NO., STREET, BARANGAY, CITY /MUNICIPALITY ZIP CODE TELEPHONE NO.
- ---
LOCATION OF CONSTRUCTION LOT NO. l:lLK. NO. TCT NO. TAX DEC. NO.
-
STREET BARANAGAY
- - - -
CITY /MUNICIPALITY OF
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SCOPE OF WORK
0 NEW CONSTRUCTION 0 RENOVATION 0 DEMOLITION
0 ERECTION 0 CONVERSION 0 ACCESSORY BUI LDING/STRUCTURE
0 ADDITIONAL 0 REP/\IH 0 OTHERS (specify)
0 ALTERATION 0 MOVING
- - -- -- -
BOX 2(TO BE ACCOMPLISHED BY THE DESIGN PROFFESSIONAL)
INSTALLATION AND OPERATION OF:
WATER SUPPLY: SYSTEM OF DISPOSAL:
0 SHALLOW WELL [_:] WASTE WATER TREATMENT PLANT 0 SURFACE DRAINAGE
0 DEEP WELL & PUMP SET L.] IMHOFF TANK 0 STREET CANAL
0 CITY/MUNICIPAL WATER SYSTEM 0 SANITARY SEWER CONNECTION 0 WATER COURSE
0 OTHERS (Specify) 0 SUB-SURFACE SAND FILTER 0 OTHERS (Specify) ____ _
PREPARED BY: -----------
'----------------------- --- ---- - ------- -----------------------__/
BOX3 BOX4
- -
'
'I
DESIGNE PROFESSIONAL, PLANS AND SPECIFICATION SUPERVISOR OF SANITARY WORKS
SANITARY ENGINEER
SANITARY ENGINEER
(Signature Over Printed Name) (Signature Over Printed Name)
---
Address
-
Address
PRC No. Validity PRC No. Validity
- -
PTR No. Date Issued PTR No. Date Issued
-
Issued at TIN 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
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BOX 7 (SUBMITTALS TO CHECKED, RECEIVED AND RECORDED)
RECEIVED BY:
- -----'--=D-'-'A-'-' TE::..:: _ __________________ _ -1
FIVE (5) SETS OF SANITARY DOCUMENTS
0 SANITARY PLANS AND SPECIFICATIONS
0 COST ESTI MATES
0 BILL OF MATERIALS
0 OTHES (Specify)--------
BOX 8 (TO BE ACCOMPLISHED BY THE SANITARYSECTION OF THE OFFICE OF THE BUILDING OFFICIAL) To be shown to the applicant.
PROGRESS FLOW
REVIEWED:
T-
IN OUT
CHIEF, SANITARY SECTION

ACTION/ REMARKS PROCESSED BY
RECEIVING AND RECORDING
SANITARY -
OTHERS (Specify)
_l_
BOX 9 (TO BE ACCOMPLISHED BY THE SANITARY SECTION OF THE OFFICE OF THE BUILDING OFFICIAL)
-
ASSESSED FEES
AMOUNT DUE ASSESSED BY O.R. NUMBEf DATE PAID REVIEWED BY:
SANITARY
OTHERS (Specify)
CHIEF. PROCESSING AND EVALUATION DIVISION
BOX10
ACTION TAKEN:
PERMIT IS HEREBY ISSUED SUBJECT TO THE FOLLOWI NG:
1. THAT THE DESIGNER IS AWARE THAT UNDER ARTICLL 1723 OF THf CIVIL CODE OF THE PHILIPPINES, HE/SHE IS RESPONSIBLE FOR DAMAGES IF IT SHOULD COLLAPSE WI THIN FIFTEEN (15) YEARS FROM THE COMPLETION OF 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/STRUCTURE WAS DESIGNED ARE NOT BEING VIOLATED OR ABUSED.
2. THAT THE PROPOSED SANITARY WORKS SHALL BE IN ACCORDANCE WITH THE SANITARY PLANS FILED WITH THIS OFFICE AND IN CONFORMITY WITH THE LATEST CODE ON SANITATION OFTHE PHILIP[PINES,TIIl CODE AND ITS IRR.
3. THAT UPON COMPLETION OF THE SANITARY WORKS, THE LICENSED SUPERVISOR SHALL SUBMIT THE ENTRY TO THE LOGBOOK DULY SIGNED AND SEALED TO THE BUILDING OFFICIAL INCLUDING AS-BUILD PLANS liND OTHER DOCUMENTS AND SHALL ALSO ACCOM PLISH THE CERTIFICATE OF COMPLETION STATING THAT THE SANITARY WORKS CONFORM TO THE PROVISION OF THE CODE ON SANITATION,THE CODE AND ITS IRR.
4. THAT THIS PERMIT IS NULL AND VOID UNLESS ACCOMPliSHED BY THE BUILDING PERMIT.
RECOMMENDING ISSUANCE OF SANITARY PERMIT:
PERMIT ISSUED:
- CHI EF,-SANITARY SECTION
(Signature Over Printed Na me)
Date --- - ----
CHIEF-;-P-ROCESSING AND EVALUATION DIVISION
(Signature Over Printed Name)
Date--------

(Building Official)
Date
l
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