NBC FORM NO.
A-07
Republic of the Philippines
City Dapitan City
Province of Zamboanga del Norte
OFFICE OF THE BUILDING OFFICIAL
ELECTRONICS PERMIT
APPLICATION NO. ELP NO. BUILDING PERMIT NO.
BOX 1 (TO BE ACCOMPLISHED BY THE OWNER / APPLICANT)
OWNER/APPLICANT LAST NAME FIRST NAME M.I. TIN
FOR CONSTRUCTION OWNED FORM OF OWNERSHIP USE OR CHARACTER OF OCCUPANCY
BY AN 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 INSTALLATION ANNUAL INSPECTION OTHERS (Specify) _____________________
BOX 2 (TO BE ACCOMPLISHED BY THE DESIGN PROFESSIONAL)
NATURE OF INSTALLATION WORKS/EQUIPMENT SYSTEM:
TELECOMMUNICATION SYSTEM ELECTRONICS FIRE ALARM SYSTEM ELECTRONICS COMPUTERIZED
PROCESS AUTOMATION SYSTEM
BROADCASTING SYSTEM SOUND COMMUNICATION SYSTEM BUILDING AUTOMATION MANAGEMENT
AND CONTROL SYSTEM
TELEVISION SYSTEM CENTRALIZED CLOCK SYSTEM BUILDING WIRING UTILIZING COPPER
CABLE, FIBER OPTIC, CABLE OR OTHER
MEDIAL ELECTRONICS SYSTEM
INFORMATION TECHNOLOGY SYSTEM ELECTRONICS CONTROL AND CONVERYOR SYSTEM
ANY OTHER ELECTRONICS AND I.T. SYSTEMS, EQUIPMENT, APPARATUS, DEVICE AND/OR COMPONENT (Specify)
__________________________
PREPARED BY: ____________________________________________________________________________________________
BOX 4
BOX 3
DESIGN PROFESSIONAL, PLANS AND SPECIFICATIONS SUPERVISOR / IN-CHARGE OF ELECTRONICS WORKS
__________________________________ Date_____________ __________________________________ Date_____________
ELECTRONICS ENGINEER ELECTRONICS ENGINEER
(Signed and Sealed Over Printed Name) (Signed and Sealed 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
BOX 5 BOX 6
BUILDING OWNER WITH MY CONSENT: LOT OWNER
______________________________________________ ______________________________________________
(Signature Over Printed Name) (Signature Over Printed Name)
Date: ______________________ Date: ______________________
Address: Address:
C.T.C. No. Date Issued Place Issued C.T.C. No. Date Issued Place Issued
NBC FORM NO. A-07
TO BE ACCOMPLISHED BY THE PROCESSING AND EVALUATION DIVISION
BOX 7
RECEIVED BY: DATE:
FIVE (5) SETS OF ELECTRONICS DOCUMENTS
ELECTRONICS PLANS AND SPECIFICATIONS COST ESTIMATES
BILL OF MATERIALS OTHERS (Specify) ______________________________
BOX 8
PROGRESS FLOW
IN OUT
PROCESSED BY:
DATE TIME DATE TIME
ELECTRONICS
OTHERS (Specify)
BOX 9
ACTION TAKEN:
PERMIT IS HEREBY ISSUED SUBJECT TO THE FOLLOWING:
1. That the proposed electronics works shall be in accordance with the electronics plans filed with this Office and in
conformity with the latest Electronics Code of the Philippines, the National Building Code and its IRR.
2. That prior to any electronics installation, a duly accomplished prescribed “Notice of Construction” shall be submitted to
the Office of the Building Official.
3. That upon completion of the electronic works, the licensed supervisor / in-charged shall submit the entry to the logbook
duly signed and sealed to the building official including as-built plans and other documents and shall also accomplish the
Certificate of Completion stating that the electronic works conform to the provision of the Electronics Code of the
Philippines, the National Building Code of IRR.
4. That this permit is null and void unless accompanied by the building permit.
PERMIT ISSUED BY:
Building Official
(Signature Over Printed Name)
Date: ______________________