Republic of the Philippines

OFFICE OF THE BUILDING OFFICIAL

Lucena City
AREA CODE : 042

APPLICATION NO : PERMIT NO.

______________________________ ________________________________
______________________________ ________________________________
Date of Application Date of Completion

DEMOLITION PERMIT APPLICATION

I HAVE THE HONOR TO APPLY FOR A PERMIT TO DEMOLISH A ________________________

BUILDING / STRUCTURE, LOCATED AT _____________________________________________________
SHOWN IN THE SKETCH AT THE BACK OF THE FORM.

IN THIS CONNECTION, I CERTIFY TO THE FOLLOWING:

1. THE UNDERSIGNED IS THE BONAFIDE OWNER (AUTHORIZED REPRESENTATIVE)

OF THE BUILDING / STRUCTURE TO THE DEMOLISHED.
2. THE BUILDING / STRUCTURE IS NOT LEASED TO ANY OTHER PARTY IS NOT
INVOLVED IN ANY COURT LITIGATION.
3. THE SUBJECT BUILDING / STRUCTURE IS ALREADY VACATED AND ALL UTILITY
LINES SUCH AS WATER, ELECTRIC, GAS AND TELEPHONE HAVE ALREADY BEEN
DISCONNECTED.
4. THE REAL ESTATE TAX OF SUBJECT BUILDING / STRUCTURE HAS BEEN PAID FOR
THE CURRENT YEAR AS PER HEREIN ATTACHED COPY OF THE RECEIPT.
5. THE PROPOSED DEMOLITION SHALL BE UNDERTAKEN UNDER THE DIRECT
SUPERVISION OF _______________________________________________, A LICENSED
ARCHITECT / CIVIL ENGINEER WHO SIGNIFIED HIS/HER ACCEPTANCE OF THIS
RESPONSIBILITY BY AFFIXING HIS/HER SIGNATURE AND SEAL HEREUNDER.

_____________________________________ _________________________________________
ARCHITECT/CIVIL ENGINEER OWNER/AUTHORIZED REPRESENTATIVE

PRC REG. NO. ________________________ TIN _____________________________________

PTR NO. _____________________________ ADDRESS _______________________________
DATE ISSUED _______________________ ________________________________________
PLACE ISSUED ______________________
_____________________________________

CONFORME:
____________________________
LOT OWNER
_________________
TIN
_________________________________________________________________________________________
_REPUBLIC OF THE PHILIPPINES)
_____________________________ ) S.S.
BEFORE ME, A NOTARY PUBLIC IN AND FOR THE _____________________________________
PHILIPPINES THIS TO ME AS THE PERSON WHO EXPECTED THE FOREGOING INSTRUMENT AND
HE/SHE ACKNOWLEDGE TO ME THAT SAME IS HIS/HER FREE AND VOLUNTARY ACT AS DEE.

IN WITNESS HEREOF, I HAVE HEREUNTO AFFIXED MY HAND AND NOTARIAL SEAL ON

THE DATE AND PLACE ABOVE STATED.

SUBSCRIBED AND SWORN TO BEFORE ME this ______ day of ________________, 200___ at

Lucena City.

____________________________________
NOTARY PUBLIC
Book No. ___________ UNTIL _____________________________
Page No. ___________ ON ________________________________
Doc. No. ___________ T __________________________________
Series of ____________