BWC-ISD-T-5

Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

Region XII, Mabini Extension, Koronadal City

APPLICATION FOR INTERNAL COMBUSTION ENGINE INSTALLATION

1. Name of Establishment: _____________________________________________
2. Address: _________________________________________________________
3. Owner/Manager & His Address: ______________________________________
4. Where machinery is to be installed: ____________________________________
________________________________________________________________
5. Installation permanent or Temporary: __________________________________
6. Machinery Data:
(a) Name: _____________________________________________________
(b) Type & Model: _______________________________________________
(c) Bore: _______________________
(d) Stroke: __________________
(e) No. of Cylinder________________
(f) Cycle:___________________
(g) Power ______________________
(h) R.P.M.: _________________
(i) Kind of I C E__________________
(j) Engine Weight: ____________
7. Name & Signature of person to supervise the installation:
________________________________________________________________
and _____________________________________________________________
(Board of Mechanical Engineering License, if any)
8. Other Accessories or equipment: ______________________________________
________________________________________________________________
________________________________________________________________

_____________________________
(Name & Signature of Manager)
Tax Identification No__________________

Application No.: _______________________

Plan Fee:_____________________________
O R No._____________Date_____________
Date Received:________________________
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Note:
This application must be accompanied by a foundation and installation plan prepared,
signed and sealed by a Professional Mechanical Engineer.