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Renewal of CPC with Extension of Service Application Form
NWRB renewal application form for CPC with extension of Service
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
APPLICATION FOR RENEWAL OF CPC
NATIONAL WATER RESOURCES BOARD
WITH EXTENSION OF SERVICE
th Floor, NIA Building, EDSA, Quezon City
8
Telefax : 920-27-14
CASE NO.
PLEASE ACCOMPLISH THIS FORM IN SIX (6) COPIES
NAME OF APPLICANT
WATER PERMIT NO.
MAILING ADDRESS
SOURCE
LOCATION
CITIZENSHIP
EXISTING SERVICE AREA
Subdivision :
CONTACT NO.
TIN
DATE OF OPERATION
SERVICE AREA TO BE EXTENDED:
Existing CPC/CPCN No.
Barangay :
Provisional Authority Required
Yes
Municipality :
TYPE OF UTILITY
[ ] Subdivision / HOA
[ ] RWSA
[ ] Cooperative
[ ] Bulk Water Seller/Peddler
[ ] Others
________________________
(specify)
NO. OF CONNECTIONS
a. with water meters _______________
b. w/o water meters _______________
c. meter tested
________________
c.1 tested by ________________
c.2 date tested _________________
d. for bulk seller /peddler
Average volume of water delivered in
cubic meters per day ___________
No
FILLING FEE
a. Amount ____________
b. O. R. No. ___________
c. Date ________________
KIND OF WATER SYSTEM
[ ] Draw & Fill
[ ] Float
[ ] Direct Pumping
LIST OF DOCUMENTARY REQUIREMENTS
NOTE: USE 5-YEAR TARIFF MODEL TO COMPLY ON
FINANCIAL REQUIEMENTS
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
Articles of Incorporation/Partnership/DTI Registration
Board resolution (for corporations and partnerships)
or special power of attorney (for single
proprietorships) authorizing the signatory to sign and
file the application
Copy of Approved Water Permit/s
Copy of Official Receipt/s of Annual Water Charges
& Supervision and Regulation Fee
Copy of Latest Certificate of Potability issued by
City/Municipal Health Officer where source is located
with Results of Bacteriological, Physical & Chemical
Impurities conducted by laboratory of DOH
Copy of Latest Annual Report
Plan of Water Distribution System
Plan, Elevation of Cross-sectional Views of
Tank/Reservoir
Plan, Elevation of Cross -sectional Views of Pump
House, Machinery & Equipment
CPC Certificate/Diploma
(
(
(
(
)
)
)
)
( )
( )
( )
( )
( )
Latest Audited Financial Statements ¹
Actual Balance Sheet for Water Operations ¹
Actual Income Statement for Water Operations ¹
List of Existing Assets in Service Subject to Return ¹
Itemized Projected Financial Statements for Water
Operations for 5 years
( ) Income Statements
( ) Funds Flow
( ) Balance Sheet
( ) Assumptions
Comparative statements showing revenue based on the
present authorized rates and on the proposed increased of
rates
Business Plan & Itemized List of Required Investments
for the Next 5 yrs.
Proposed Tariff Schedule
Levels of service agreed with consumers commensurate
with proposed rates
Others
I HEREBY CERTIFY THAT THE INFORMATION GIVEN
ABOVE AND THE DOCUMENTS SUBMITTED ARE TRUE
AND CORRECT TO THE BEST OF KNOWLEDGE AND
BELIEF
SUBSCRIBED AND SWORN TO BEFORE ME ON
THIS DATE
Signature of Water Utility Representative
Notary Public / Administering Officer
