Application No. Date Received: O.R. No.

Date Issued: Amount Paid:

HOUSING AND LAND USE REGULATORY BOARD REGION IX , ZAMBOANGA CITY

APPLICATION FOR LOCATION CLEARANCE / CERTIFICATE OF ZONING COMPLIANCE 1. NAME OF APPLICANT ( LAST , FIRST , M.I. ) 2. NAME OF CORPORATION

3. ADDRESS OF APPLICANT:

4. ADDRESS OF CORPORATION

5. NAME OF AUTHORIZED REPRESENTATIVE

6. ADDRESS OF AUTHO. REPRESENTATIVE

7. PROJECT TYPE:

8. PROJECT AREAS (S.M.) Lot Bldg.

9. PROJECT LOCATION (St,Brgy,City,Mun,Prov)

10. PROJECT NATURE New Dev't. [ ] Others: 12. PROJECT NATURE [ ] Permanent [ ] Temporary (Specify)

11. RIGHT OVER LAND [ ] Owner [ ] Lessee [ ] Others (Specify): 13. EXISTING LAND USE OF PROJECT SITE: [ ] Residential [ ] Institutional [ ] Industrial

[ ] Other Specify

14. PROJECT COST / CAPITALIZATION (In pesos, write in figures and words)

15. IS THE PROJECT APPLIED FOR A SUBJECT OF WRITTEN NOTICES FROM THIS OFFICE & / OR IT'S DEPUTILIZED ZONING ADMINISTRATOR TO THE EFFECT REQUIRING FOR PRESENTATION OF LOCATION CLEARANCE / CERTIFICATE OF ZONING COMPLIANCE (LC / CZC) OR TO APPLY FOR LC / CZC? ( ) YES ( ) NO. IF YES, PLEASE ANSWER THE FOLLOWING; 15A Name of officer or zoning Administrator who issued the Notice 15b Date of Notice 15c Orders / request indicated in the Notice

16. IS THE PROJECT APPLIED FOR THE SUBJECT OF SIMILAR APPLICATION (S) WITH OTHER OFFICES OF THE HLRB AND / OR DEPUTIZED ZONING ADMINISTRATOR? ( ) YES ( ) NO Please answer the following : 16a other HLRB OFFICES where similar application (s) was / were filled Date Filed 17. PREFERRED MODE OF RELEASE OF DECISION: ( ) Pick-up ( ) Authorized Representative ( ) By mail address to:

18. SIGNATURE OF APPLICANT:

19. SIGNATURE OF AUTHO. REPRESENTATIVE

REPUBLIC OF THE PHILIPPINES

) ) S.S. ) day, on of ,2006 in the City / Municiplaity of Affiant exibiting to me his/her residence Certificate No. , 2006 NOTARY PUBLIC

SUBSCRIBE AND SWORN to before me this province of issued at Doc. No. Page No. Book No. Series of

e of Notice

Municiplaity of ificate No.