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Application Form
LLDA clearance application form for development plan, program and projects in Laguna bay region
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: LAGUNA LAKE DEVELOPMENT AUTHORITY
National Ecology Center, East Avenue
Diliman, Quezon City
Tel. Nos.: 332-2346, 376-4039, 376-4072, 376-4049, 376-4061
CLEARANCE APPLICATION FOR DEVELOPMENT PLAN/PROGRAM/PROJECT IN
THE LAGUNA de BAY REGION
LLDA CLEARANCE
AMENDMENT
EXEMPTION
EXPANSION
PART I – APPLICANT INFORMATION
Name of Establishment:
_______________________________________________________
Tax Identification Number (TIN): __________________________ Year Established: ___________
Business Address:
Number and Street: _______________________________ Barangay: ______________________
City/Municipality: _________________________________ Province: _______________________
GPS Coordinates: (Latitude) ________________________ (Longtitude) _____________________
Name & Location of Project/Development:
Project Name (if any): ____________________________________________________________
Number and Street: _______________________________ Barangay: ______________________
City/Municipality: _________________________________ Province: _______________________
Chief Executive Officer of the Establishment:
Name: ___________________________________ Title/Designation: ______________________
Tel #: ____________ Fax #: _____________ Cel #: _____________ email add: ______________
Applicant’s Authorized Representative/Pollution Control Officer:
Name: ____________________________________Title/Designation: ______________________
Name of Firm: __________________________________________________________________
Number and Street: _______________________________ Barangay: ______________________
City/Municipality: ________________ Province: _______________Tel. # :___________________
Fax #: _________________ Cel. #: ________________ email add: ________________________
PART II – BUSINESS ACTIVITY DESCRIPTION
I. Business Activity: _______________________________
Production Capacity (allowed per ECC): ________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
(continuation at the back)
LLDA-CPD-Form 01
Issue Date: November 2015
Issue No.: 02
A. Industrial Establishment/Infrastructure Projects and other similar project
Capital Investment (Authorized Capital Stock): PhP________________________
Total Project Cost: _____________________________
B. Agro-Industrial Establishment
Capacity (Maximum No. of Heads): ___________________________________________
C. Housing Development, Institution, Hospital, Commercial Establishments, Parks,
Golf Course warehouse/storage facilities, etc.
Gross Floor Area (sq.m): __________________ Total Lot Area (sq.m): ________________
For Townhouses/Villas/other cluster housing units (total no. of units): _________________
D. Other Projects (Land Transport Terminal/Parking Areas)
No. of vehicle slots: ___________________
II. Employment and Operation Information
Total Employment (number of workers)
Production: ________________
Non-Production: ____________
Operational Schedule/Time
No. of hours/day: _________ shifts/day: _____
No. of days/month: _______________
PART III – WATER SUPPLY, WASTEWATER GENERATION, TREATMENT AND DISPOSAL
Sources of Water Supply
MWSI/MWCI ( )
Rivers ( )
Local Water District ( )
Others ( )
Deepwell ( )
Laguna de Bay ( )
Total Water Consumption (m3/day): ____________________
Wastewater Generation, Treatment and Disposal
Total Volume of Wastewater Discharge (m3/day): ___________________
Method of Treatment: _________________________________________
Disposal: ____________________________________________________
I certify that the information above are true, complete and accurate to the best of my knowledge.
_________________________________________
_______________________________
Signature of Representative/Pollution Control Officer
Signature of Chief Executive Officer
Date: _________________________
Date: ________________________________
SUBSCRIBED AND SWORN to before me a NOTARY PUBLIC, this ______ day of
________________, affiant exhibiting to me his/her Community Tax Receipt No. _________________ issued
at ________________ on ___________________
NOTARY PUBLIC
Doc. No. ________
Page No. ________
Book No. ________
Series No. ________
All information contained in this application form will be held strictly confidential.
LLDA-CPD-Form 01
Issue Date: November 2015
Issue No.: 02
