DPWTC FORM NO.
77-001-M
REPUBLIC OF THE PHILIPPINES
OFFICE OF THE BUILDING OFFICIAL
CITY ENGINEER’S OFFICE
LAPU-LAPU CIY
APPLICATION NO. PERMIT NO.
_________________________ MECHANICAL PERMIT _________________________
DATE OF APPLICATION DATE ISSUED
BOX 1 ( TO BE ACCOMPLISHED BY PROFESSIONAL MECHANICAL ENGINEER IN PRINT )
NAME OF: OWNER/APPLICATION LAST NAME, FIRST NAME, M.I TAX IDENTICATION NO.
ADDRESS NO., STREET, BARANGAY, CITY/ MUNICIPALITY TELEPHONE NO.
LOCATION OF INSTALLATION NO., STREET, BARANGAY, CITY/ MUNICIPALITY
SCOPE OF WORK ADDITION OF ___________________ BUILDING PERMIT NO.
NEW INSTALLATION REMOVAL OF ___________________ _____________________
OTHERS (SPECIFY) ______________ CERTIFICATE OF ACCUPANCY NO.
______________________________
USE OR TYPE OF OCCUPANCY
RESIDENTIAL AGRICULTURAL
COMMERCIAL . LANDSCAPING
INDUSTRIAL OTHERS (SPECIFY)
. INSTITUTIONAL ____________________________
INSTALLATION AND OPERATION OF
BOILER . CENTRAL AIR-CONDITIONING DUMBWATER
PRESSURE VESSELS MECHANICAL VENTILATION PUMPS
INTERNAL COMBUSTION ENGINE ESCALATOR COMPRESSED AIR, VACUUM
REFREGERATION & ICE MAKING MOVING SIDEWALK INSTITUTION and/or INDUS
WINDOW TYPE AIR-CONDITIONING FREIGHT ELEVATOR TRIAL GAS
PACKAGE AIR-CONDITIONING UNIT PASSENGER ELEVATOR PNEUMATIC TUBE,
CONVEYORS and/ or MONORAILS
✔ OTHER (SPECIFY) ________________________________________________________________________________
PROPOSED DATE EXPECTED DATE
OF INSTALLATION__________________________________ OF COMPLETION___________________________
TOTAL INSTALLATION COST ________________________ PREPARED BY ____________________________
BOX ( TO BE ACCOMPLISHED BY THE BUILDING OFFICIAL )
ACTION TAKEN:
PERMIT IS HEREBY GRANTED TO INSTALL THE MECHANICAL
EQUIPMENT ENUMERATED HEREIN SUBJECT TO THE FOLLOWING
CONDITIONS.
1. THAT THE PROPOSED INSTALLATION SHALL BE IN ACCORDANCE WITH
APPROVED PLANS, FILED WITH THIS OFFICE AND IN CONFORMITY
WITH THE “NATIONAL BUILDING CODE”
2. THAT A DULY LICENSED PROFESSIONAL MECHANICAL ENGINEER BE
ENGAGED TO UNDERTAKE THE INSTALLATION/COMSTRUCTION.
3. THAT A CERTIFICATION OF COMPLETION DUTY SIGNED BY A PROFES-
SIONAL MECHANICAL ENGINEER IN-CHARGE OF INSTALLATION SHALL
BE SUBMITTED NOT LATER THAN SEVEN (7) DAYS AFTER COMPLETION __________________________________
OF THE INSTALLATION. BUILDING OFFICIAL
4. THAT A CERTIFICATE OF FINAL INSPECTION AND A CERTIFICATE OF OCCU-
PANCY BE SECURED PRIOR TO THE ACTUAL OCCUPANCE OF THE BUILDING.
5. THAT AN ANNUAL CERTIFICATE OF INSPECTION SHALL BE SECURED FOR ________________________________
THE CONTINOUS OPERATION OF THE MECHANICAL EQUIPMENT INSTALLER. DATE
NOTE:
THIS PERMIT MAY BE CANCELLED OR REVOKED PURSUANT TO SECTION 305 & 306 OF THE “ NATIONAL BUILDING
CODE”
BOX 3 ( TO BE ACCOMPLISHED BY THE RECEIVING AND RECORDING SECTION )
BUILDING DOCUMENTS
(FIVE (5) SETS EACH)
MECHANICAL PLANS & SPECIFICATIONS BILL OF MATERIALS
COST ESTIMATES OTHERS (SPECIFY)
BOX 4 ( TO BE ACCOMPLISHED BY THE DIVISION/SECTIION CONCERNED )
ASSESSED FEE
AMOUNT ASSESSED BY O.R NUMBER DATE PAID
MECHANICAL
REVIEWED :
CHIEF PROCESSING DIV./SEC.
BOX 5 ( ( TO BE ACCOMPLISHED BY THE DIVISION/SECTIION CONCERNED )
PROGRESS FLOW
NOTED: IN OUT ACTION/REMARKS PROCESSED BY
CHIEF PROCESSING
DIVISION/ SECTION DATE TIME DATE TIME
RECEIVING AND
RECORDING
MECHANICAL
WERE HEREBY AFFIX OUR HANDS SGNFYING OUR CONFORMITY TO THE INFORMATION HEREIN ABOVE SETFORTH
BOX 6 BOX 8
PROF. MECH. ENGINEER PRC. REG. NO. SIGNATURE
SIGNED AND SEALED PLANS & SPECIFICATION
PRINT NAME
APPLICANT
ADDRESS
RES. CERT. NO DATE ISSUED PLACE ISSUED
P.T.R. NO. DATE ISSUED PLACE ISSUED
SIGNATURE TIN
BOX 7
PROF. MECH. ENGINEER PRC. REG. NO.
IN-CHARGE OF INSTALLATION
PRINT NAME
ADDRESS
P.T.R. NO. DATE ISSUED PLACE ISSUED
SIGNATURE
Republic of the Philippines
Office of the Building Official
Lapu- lapu City
MECHANICAL WORKSHEET
MECHANICAL SECTION
Name of User/Establishment:____________________________________________________
Owner/Manager:_______________________________________________________________
Location:_____________________________________________________________________
QTY EQUIPMENT/ MACHINERY RATING
Floor Mounted Airconditioners TR
Split type Airconditioners TR
Cassette type Airconditioners TR
Window Type Airconditioners TR
Exhaust fans KW
Internal Combustion Engine KW
Boiler (Firetube, Watertube) KW
Elevetor (Passenger,Freight,Dumbwaiter) STOPS
Escalator/ Moving Walk KW
Water Heater KW
Water pump,Sum pump, Sewage pump KW
Sprinkler System (Pendent, Upright, Sidewall) HEADS
Compressed Air. Vacuum, Industrial Gases OUTLETS
Power Piping for Gas/Steam etc. METER
Conveyor, Monorials, Overhead Crane M3
Other Machinery KW
Remarks: ______________________________________________________________________________
I hereby CERTIFY that the above data and information are connect to the best of my knowledge and
belief.
Prepared by: Must be signed & Sealed by Noted by:
Professional Mechanical Engineer
_____________________________ __________________________
Signature over Printed Name Signature over Printed Name
PRC ID ______________________
Expire Date __________________
PTR No. _____________________
Date Issued __________________
