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DPWH- QMSP-16-46-Rev 00
Department of Public Works and Highways
Quality Management System
APPLICATION FOR ISSUANCE OF DIGGING/EXCAVATION PERMIT
Per Department Order No. Series of,
Date of Filing:
NAME OF UTILITY AGENCY/COMPANY:
‘ADDRESS OF UTILITY AGENCY/COMPANY:
NAME OF UTILITY CONTRACTOR AND ADDRESS:
PROJECT NAME:
LOCATION OF PROJECT:
‘SCOPE OF WORK:
DURATION OF WORK: H, ATTACHMENT (Please check the appropriate box)
Program of Works (POW) and Detailed Unit Price Analysis (DUPA)
Geotagged Pictures, (Annex 8)
Utility Lay-Out Plan, (Annex C)
Cross-Sectional Plan and Specifications showing the proposed utility facility to be
embedded in the actual road (including profile, the scope of works and
specifications for the restoration activity, and traffic management plan. Cross-section
at the start, end, and every change in utility and road features must be exhibited in
the plan
Precedence Diagram Method (PDM)
Notarized Authorization Letter from the Utiity Agency/Company
Notarized Terms and Conditions signed by the duly authorized representative of the
Applicant (Annex D).
Performance Security
[Surety Bond and Official Receipt together with Certificate of Authority from the
Insurance Commission, 100% of the full restoration/reconstruction cost of the
affected area, for above P50,000.00.
Cash Bond, 100% of the full restoration/reconstruction cast if the cost of
restoration is P50,000.00 and below
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Thereby certify thet the information contained in this application, including inthe attachments, is true
and accurate, T understand that the same is subject to evaluation and verification. This, any
Imisrepresentation in this application may cause legal action against me andjor the agency/company 1
represent.
Submitted By:
Name & Signature of the Applicant's Authorized Representative
(To be hited out by the DPWH Maintenance Technical Personnel)
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Evaluated by:
Lee
Name & Signature of DPWH Maintenance Technical Personnel : ANNEX B-4
For Utlity Agency/Company
DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS
GEOTAGGED PHOTOGRAPHS
=
Utility Agenoy/Company:
Utility Contractor:
Permit Nc
(PICTURE 1)
(PICTURE 2)
(PICTURE 3)
‘Note: Photographs shall have the same angle of shooting with an identified
fandmaridbackgroundiraference point.
Prepared and submitied by:
(SIGNATURE OVER PRINTED NAME}
Utlty Agency/Company Representative