Application Form

LLDA application form for shoreland development clearance permit

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

APPLICATION FOR SHORELAND DEVELOPMENT CLEARANCE
APPLICANT'S INFORMATION
[ ] LGU

[ ] INDIVIDUAL

[ ] COOPERATIVE

[ ] PRIVATE COMPANY

NAME OF APPLICANT

BUSINESS ADDRESS

TELEPHONE NO.

FAX NO.

E-MAIL

FOR INDIVIDUAL APPLICANTS ONLY
AGE

CIVIL STATUS

CITIZENSHIP

PLACE OF BIRTH

CITIZENSHIP

NAME OF SP0USE (IF MARRIED)

DATE OF BIRTH

DATE OF BIRTH

PLACE OF BIRTH

RESIDENCE CERT. NO.

LOCATION/USE OF SHORELAND AREA
IS THE SHORELAND AREA APPLYING FOR TITLED? [ ] YES

[

] NO

IF YES:
LOCATION OF SHORELAND (COMPLETE ADDRESS)

APPROXIMATE GEOGRAPHIC COORDINATES

LOT OWNER

OCT NUMBER

DATE ISSUED

TOTAL AREA

TCT NUMBER

DATE ISSUED

ADJOINING/ADJACENT STREET

BARANGAY

TOWN/CITY

PROVINCE

APPROXIMATE AREA (IN SQUARE METERS)

NOTE:

SPECIFY TYPE OF DEVELOPMENT

IF NO:

SUBJECT TO ACTUAL VERIFICATION
PURPOSE OF APPLICATION/TYPE OF DEVELOPMENT

APPLICANT'S AUTHORIZED REPRESENTATIVE
NAME OF AUTHORIZED REPRESENTATIVE

BUSINESS ADDRESS

TELEPHONE NO.

FAX NO.

E-MAIL

I do hereby certify the information supplied are true and correct in my knowledge and belief. I
understand that the information contained herein shall be subject to verification and that my false
statements shall be ground for rejection of this application.

____________________________________
Name & Signature of the Authorized Representative

________________________________________
Name & Signature of the President/Owner

Date: _______________________
LLDA-CPD-Form 36

Date: _______________________
Issue Date: May 2015

Issue No.: 01