5 Mechical Forms

NBC FORM NO. A - 04 / REVISION NO.
01 / 10-01-2019
REPUBLIC OF THE PHILIPPINES

PROVINCE OF PAMPANGA
CITY OF SAN FERNANDO
OFFICE OF THE BUILDING OFFICIAL
AREA CODE: 5416W
MECHANICAL PERMIT
APPLICATION NO. MECHANICAL 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, B ARANGAY CITY/MUNICIPALITY ZIP CODE TELEPHONE NO.
LOCATION OF CONSTRUCTION: LOT NO. ________ BLK NO. ________ TC NO. _________ TAX DEC. NO. _______
STREET ________________ BARANGAY __________________________ CITY/MUNICIPALITY ________________________
SCOPE OF WORK
NEW CONSTRUCTION RENOVATION ________________ RAISING ___________________________
ERECTION ________________ CONVERSION _________________ DEMOLITION _______________________
ADDITION ________________ REPAIR ______________________ ACCESSORY BUILDING/STRUCTURE __________
ALTERATION ______________ MOVING _____________________ OTHERS (Specify) _____________________
BOX 2 (TO BE ACCOMPLISHED BY THE DESIGN PROFESSIONAL)
INSTALLATION AND OPERATION OF:

[ ] BOILER [ ] CENTRAL AIRCONDITIONING [ ] DUBMWATER
[ ] PRESSURE VESSEL [ ] MECHANICAL VENTILLATION [ ] PUMPS
[ ] INTERNAL COMBUSTION ENGINE [ ] ESCALATOR [ ] COMPRESSED AIR VACUUM,
[ ] REFRIGERATION AND ICE MAKING [ ] MOVING SIDEWALK INSTITJUTIONAL and/or INDUSTRIAL GAS
[ ] WINDOW TYPE AIRCONDITIONING [ ] FREIGHT ELEVATOR [ ] PNEUMATIC TUBES, CONVEYORS and/or
[ ] PACKAGED/SPLIT TYPE AIRCON [ ] PASSENGER ELEVATOR MONORAILS
[ ] OTHERS (Specify)________________ [ ] CABLE CAR [ ] FUNICULAR
PREPARED BY: ________________________________________________________________________________________________________________________
BOX 3 BOX 4
DESIGN PROFESSIONAL, PLANS AND SPECIFICATIONS SUPERVISOR / IN-CHARGE OF MECHANICAL WORKS

[ ] PROFESSIONAL MECHANICAL ENGINEER [ ] MECHANICAL ENGINEER
_______________________________________________ _______________________________________________
PROFESSIONAL MECHANICAL ENGINEER PROFESSIONAL MECHANICAL 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 4
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
TO BE ACCOMPLISHED BY THE PROCESSING AND EVALUATION DIVISION
BOX 7
RECEIVED BY: DATE:
FIVE (5) SETS OF MECHANICAL DOCUMENTS
[ ] MECHANICAL PLANS AND SPECIFICATIONS [ ] COST ESTIMATES
[ ] BILL OF MATERIALS [ ] OTHERS (Specify) ________________________________________
BOX 8
PROGRESS FLOW
IN OUT PROCESSED BY
DATE TIME DATE TIME
RECEIVING AND RECORDING
MECHANICAL
OTHERS (Specify)
BOX 9
ACTION TAKEN:
PERMIT IS HEREBY ISSUED SUBJECT TO THE FOLLOWING:
1. That the proposed mechanical works shall be in accordance with the mechanical plans filed with this Office and in conformity with the
latest Philippine Mechanical Code, the National Building Code and its IRR.
2. That prior to any mechanical installation, a duly accomplished prescribed “Notice of Construction” shall be submitted to the Office of
the Building Official.
3. That upon completion of the Mechanical 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 mechanical works conform to the provision of the Philippine Mechanical Code, the National Building Code
and its IRR.
4. That this permit is null and void unless accompanied by the building permit.
5. That a Certificate shall be issued for the continuous use of installations.
PERMIT ISSUED BY:
BUILDING OFFICIAL
(Signature Over Printed Name)
Date ______________________
NOTE: THIS PERMIT MAY BE CANCELLED OR REVOKED PURSUANT TO SECTIONS 305 AND 306 OF THE “NATIONAL BUILDING CODE.”

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NBC FORM NO. A - 04 / REVISION NO.

REPUBLIC OF THE PHILIPPINES

BOX 1 (TO BE ACCOMPLISHED IN PRINT BY THE APPLICANT)

FOR CONSTRUCTION OWNED FORM OF OWNERSHIP USE ORCHARACTER OF OCCUPANCY

ADDRESS: NO. STREET, B ARANGAY CITY/MUNICIPALITY ZIP CODE TELEPHONE NO.

BOX 2 (TO BE ACCOMPLISHED BY THE DESIGN PROFESSIONAL)

INSTALLATION AND OPERATION OF:

PREPARED BY: ________________________________________________________________________________________________________________________

DESIGN PROFESSIONAL, PLANS AND SPECIFICATIONS SUPERVISOR / IN-CHARGE OF MECHANICAL WORKS

PTR. No. Date Issued PTR. No. Date Issued

Issued at TIN Issued at TIN

RECEIVED BY: DATE:

FIVE (5) SETS OF MECHANICAL DOCUMENTS

[ ] MECHANICAL PLANS AND SPECIFICATIONS [ ] COST ESTIMATES

[ ] BILL OF MATERIALS [ ] OTHERS (Specify) ________________________________________

PERMIT IS HEREBY ISSUED SUBJECT TO THE FOLLOWING:

5. That a Certificate shall be issued for the continuous use of installations.

PERMIT ISSUED BY:

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