Republic of the Philippines
City/Municipality of Claver
Province of Surigao Del Norte
UNIFIED APPLICATION FORM FOR BUILDING PERMIT
SIMPLE COMPLEX*
NEW RENEWAL AMENDATORY
THIS APPLIES ALSO FOR: LOCATIONAL CLEARANCE FIRE SAFETY EVALUATION CLEARANCE
APPLICATION NO. AREA
NO.
BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE APPLICANT)
OWNER/ APPLICANT LAST NAME FIRST NAME M.I. TIN
DO NOT FILL-UP (PSA USE ONLY)
FOR CONSTRUCTION FORM OF OWNERSHIP
OWNED BY AN
ENTERPRISE
ADDRESS: NO., STREET, BARANGAY, CITY/MUNICIPALITY ZIP CODE CONTACT NO.
LOCATION OF CONSTRUCTION: LOT NO. BLK NO. TCT NO. CURRENT TAX DEC. NO.
STREET BARANGAY CITY/ MUNICIPALITY OF SURIGAO
SCOPE OF WORK
NEW CONSTRUCTION RENOVATION RAISING
ERECTION CONVERSION ACCESSORY BUILDING/STRUCTURE
ADDITION REPAIR LEGALIZATION OF EXISTINGBUILDING
ALTERATION MOVING OTHERS (Specify)
USE OR CHARACTER OF OCCUPANCY GROUP H : ASSEMBLY (OCCUPANT
GROUP A : RESIDENTIAL (DWELLINGS) GROUP E : COMMERCIAL LOAD LESS THAN 1,000)
SINGLE DUPLEX RESIDENTIAL R-1, R-2 BANK STORE SHOPPING THEATER, AUDITORIUM, CONVENTION HALL,
OTHERS DRINKING / DINING CENTER / MALL GRANDSTAND/ BLEACHER
GROUP B : RESIDENTIAL ESTABLISHMENT OTHERS
HOTEL MOTEL TOWNHOUSE SHOP (i.e. DRESS SHOP, TAILORING,
DORMITORY BOARDINGHOUSE, BARBERSHOP, etc.) GROUP I : ASSEMBLY (OCCUPANT
RESIDENTIAL R-3, R-4, R-5 LODGING HOUSE OTHERS LOAD 1,000 OR MORE)
GROUP
OTHERS COLISEUM, SPORTS
CONVENTION CENTER COMPLEX,
AND SIMILAR
GROUP F : LIGHT INDUSTRIAL
C : EDUCATIONAL & RECREATIONAL FACTORY / PLANT (USING INCOMBUSTIBLE/
STRUCTURE
SCHOOL BUILDING SCHOOL AUDITORIUM, NON-EXPLOSIVE MATERIALS OTHERS
CIVIC CENTER GYMNASIUM OTHERS GROUP J : (J-1) AGRICULTURAL
CLUBHOUSE CHURCH, MOSQUE, GROUP G : MEDIUM INDUSTRIAL BARN, GRANARY, POULTRY
OTHERS TEMPLE, CHAPEL
HOUSE, STORAGE / WAREHOUSE (FOR HAZARDOUS/ PIGGERY, GRAIN MILL, GRAIN SILO
GROUP D : INSTITUTIONAL HIGHLY FLAMMABLE MATERIALS OTHERS
HOSPITAL OR SIMILAR STRUCTURE FACTORY (FOR HAZARDOUS/ HIGHLY GROUP J : (J-2) ACCESSORIES
HOME FOR THE AGED FLAMMABLE MATERIALS PRIVATE CARPORT/GARAGE, TOWER,
GOVERNMENT OFFICE OTHERS SWIMMING POOL, FENCE OVER 1.80m,
STEEL / CONCRETE TANK
OTHERS
OTHERS
OCCUPANCY CLASSIFIED TOTAL ESTIMATED COST:P
NUMBER OF UNITS BUILDING COST OF EQUIPMENT INSTALLED:
NUMBER OF STOREY ELECTRICAL P
TOTAL FLOOR AREA SQ. M. MECHANICAL P
LOT AREA SQ. M ELECTRONICS P
PLUMBING P
PROPOSED DATE OF CONSTRUCTION: EXPECTED DATE OF COMPLETION:
BOX 2
FULL-TIME INSPECTOR AND SUPERVISOR OF CONSTRUCTION WORKS (REPRESENTING THE OWNER)
Address
PRC No. Validity
ARCHITECT OR CIVIL ENGINEER PTR No. Date Issued
(Signed and Sealed Over Printed
Name) Date Issued at TIN
BOX 3 BOX 4
APPLICANT: WITH MY CONSENT: LOT OWNER / AUTHORIZED REPRESENTATIVE
Date Date
(Signature Over Printed Name) (Signature Over Printed Name)
Address Address
Gov’t Issued ID No. Date Issued Place Issued Gov’t Issued ID No. Date Issued Place Issued
BOX 5
REPUBLIC OF THE PHILIPPINES )
S.S
CITY/MUNICIPALITY OF )
BEFORE ME, at the City/Municipality of , on personally appeared the
following:
APPLICANT Gov’t Issued ID No. Date Issued Place Issued
LICENSED ARCHITECT OR CIVIL ENGINEER Gov’t Issued ID 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 same
is their 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
*May require additional requirements
BOX 6 (TO BE ACCOMPLISHED BY THE PROCESSING AND EVALUATION DIVISION)
BASIS OF AMOUNT
ASSESSED FEES ACCOUN ASSESSED BY
ASSESSMENT DUE
T
FOR ZONING (ZONING
ADMINISTRATOR):
LOCATIONAL / ZONING OF LAND
FOR BUILDING / STRUCTURE (OBO):
FILING FEE
LINE AND GRADE (Geodetic)
FENCING
ARCHITECTURAL
CIVIL / STRUCTURAL
ELECTRICAL
MECHANICAL
SANITARY
PLUMBING
ELECTRONICS
INTERIOR
SURCHARGES
PENALTIES
FOR FIRE SAFETY (BFP):
FIRE CODE CONSTRUCTION TAX
HOTWORKS
TOTAL
TERMS AND CONDITIONS:
1. The Owner/Applicant shall accomplish the prescribed Application Form, with the assistance of the
concerned design professional/s and/or the Architect/Civil Engineer, hired/commissioned by him/her as
full-time inspector/supervisor of the construction works, by filling up the necessary data / information
required thereat.
2. The fully accomplished prescribed 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 of the Philippines (PD 1096), its Revised IRR and all applicable referral codes and professional
regulatory laws, together with the other documentary requirements pursuant to Section 302 of PD
I have read this form, understood its contents and consent to the processing of my personal data. I understand
that my consent does not preclude the existence of other criteria for lawful processing of personal data, and does
not waive any of my rights under the Data Privacy Act of 2012 and other applicable laws.
SIGNATURE OVER PRINTED NAME OF OWNER/APPLICANT