REPUBLIC OF THE PHILIPPINES
NBC FORM NO. A-07 PROVINCE OF PAMPANGA
CITY OF SAN FERNANDO C.E.O
OFFICE OF THE BUILDING OFFICIAL Print in a Legal Size Paper (PH)
AREA CODE: 5416W (8.5" x 13")
Front page of Electronics Permit Form
ELECTRONICS PERMIT
*Form must be printed back to back
APPLICATION NO. ELECTRONICS PERMIT NO. BUILDING PERMIT NO.
_____________________________ _____________________________
DATE OF APPLICATION DATE ISSUED
BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE APPLICANT)
OWNER/APPLICANT LAST NAME FIRST NAME M.I TIN
FOR CONSTRUCTION OWNED FORM OF OWNERSHIP USE ORCHARACTER 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 ________________________
SCOPE OF WORK
NEW INSTALATION 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
CONTROLS AUTOMATION SYSTEM
□ BROADCASTING SYSTEM □ SOUND COMMUNICATION SYSTEM
□ BUILDING AUTOMATION MANAGEMENT AND
□ TELEVISION SYSTEM □ CENTRALIZED CLOCK SYSTEM CONTROL SYSTEM
□ INFORMATION TECHNOLOGY SYSTEM □ SOUND SYSTEM □ BUILDING WIRING UTILIZING COPPER CABLE
FIBER OPTIC CABLE OR OTHER MEDIAL
□ SECURITY AND ALARM SYSTEM □ ELECTRONICS CONTROL AND CONVEYOR SYSTEM ELECTRONICS SYSTEM
□ ANY OTHER ELECTRONICS AND I.T SYSTEMS, EQUIPMENT, APPARATUS, DEVICE AND/OR COMPONENT (Specify) _________________________
PREPARED BY: ________________________________________________________________________________________________________________________
BOX 3 BOX 4
DESIGN PROFESSIONAL, PLANS AND SPECIFICATIONS SUPERVISOR / IN-CHARGE OF ELECTRONICS WORKS
_______________________________________________ _______________________________________________
PROFESSIONAL ELECTRONICS ENGINEER PROFESSIONAL ELECTRONICS ENGINEER
(Signed and Sealed Over Printed Name) (Signed and Sealed Over Printed Name)
Date ________________ Date ________________
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
http://www.cityofsanfernando.gov.ph
C.E.O
Print in a Legal Size Paper (PH)
(8.5" x 13")
TO BE ACCOMPLISHED BY THE PROCESSING AND EVALUATION DIVISION Back page of Electronics Permit Form
BOX 7
RECEIVED BY: DATE: *Form must be printed back to back
FIVE (5) SETS OF ELECTRONICS DOCUMENTS
□ELECTRONICS PLAN AND SPECIFICATIONS □ COST ESTIMATE
□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 electronics 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 accomplished
the Certificate of Completion stating that the electronic works conform to the provision of the Electronics Code of the
Philippines, the National Building Code and its 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 ______________________
