LOCATIONAL CLEARANCE APPLICATION FORM
ANNEX A OF HLURB Memo Cir. No. 83 Series of 1986
Application No. _______________
Date of Receipt _______________
PMO/OR No. ________________
Date of Issue _________________
Amount Paid _________________
APPLICATION FOR LOCATION CLEARANCE/CERTIFICATE OF ZONING
1. Name of Applicant: 2. Name of Corporation:
3. Address: 4. Address of Corporation:
5. Name of Authorized Representative: 6. Address of Authorized Representative:
7. Project Type: 8. Project Nature:
___ New Development ___ Others(specify)
___ Existing
9. Project Location: 10. Project Tenure:
__ Permanent
__ Temporary (specify number of yrs.)
11. Right Over Land: 12. Project Area (sq. m.)
___ Owner OCT/TCT/CLOA No: ______ ___ Lot: _______________
___ Lessee Lot No. ________________ Bldg./Improvement _______________
___ Others
13. Existing Land Uses of Project Site
__ Residential __ Industrial ___ Agricultural (specify kind of crops) _________________________
__ Institutional __ Others (specify) ___ Commercial
14. Project Cost/Capitalization (Write Pesos in words)
_________________________________________________________________________________
15. Is the project applied for subject to written notice(s) from the Board and/or Deputized Zoning Administrator to the effect requiring for
presentation of Locational Clearance/Certificate of Zoning Compliance? If yes, please answer: a) Name of HLURB Officer who issued the
notice ________________ b) Date of Notice ________________ c) Order/Request indicated in the notice(s) ____________________
16. Is the project applied for, subject of similar application(s) with other offices, of the Board and/or DZA? ________ Yes,
___________ no. If yes, (a) other HLURB office where similar application was filed: ______________ (b) Date filed _____________
Action Taken ______________
17. Preferred mode of release of Decision:
___ pick up ____ mail
18. Signature of Authorized Representative:
19. Signature of Applicant/Owner:
Republic of the Philippines)
PROVINCE/CITY OF ______________
Municipality of _________________) S.S.
SUBSCRIBED AND SWORN TO before me this ____ day of ___________ 20____, in the City/Municipality of
________________ Province of ________________ affiant exhibiting to me his/her Res. Cert. No. ______________ issued at
_____________________ on ________________, 20______.
Doc. No. ______________
Page No. ______________
Book No. ______________ _________________
Series of ______________ Notary Public
LOCATIONAL CLEARANCE GENERAL REQUIREMENTS
1. APPLICATION FORM duly accomplished and notarized
2. PROOF OF OWNERSHIP OVER THE LAND to be used.
Certificate of Title or Tax Declaration in the name of the applicant or any of the following documents together
with the owner’s Certificate of Title or Tax Declaration.
2.a. Deed of Sale in the name of the applicant
2.b. Deed of Donation
2.c. Contract of Lease
2.d. Authorization to use the land from the landowner
3. VICINITY MAP (or Location Plan) showing existing land uses within 100.00 meter radius (for project of local
significance) and one (1) kilometer radius (for projects of national significance) from the lot boundary of the
project SITE.
4. SITE DEVELOPMENT PLAN (or Lot Plan) showing lot area boundaries and dimension of proposed improvements
within the project line;
5. FLOOR PLAN of the proposed/existing project.
6. CERTIFICATE OF ZONING from the City/Municipal Planning & Development Office, as to zone classification of the
proposed area;
7. BILL OF MATERIALS/ESTIMATED COST OF THE PROJECT (cost of construction including machineries/equipment’s
if any) signed by an engineer or architect;
8. FILING FEE to be computed upon submission of complete documents
9. COPY OF BUILDING PERMIT (to on-going and existing project, and TPZ monitored project)
Project Cost P ___________
LC FILING FEE ___________
SURCHARGE/FINE ___________
U.P. LR FEE (1% OF LCE FEE) ___________
TOTAL FEES ___________
ADDITIONAL REQUIREMENTS
DAR CONVERSION ORDER if the project site is within agricultural zone;
FOR INDUSTRIAL/AGRO-INDUSTRIAL PROJECT;
- Equity participating agreement/log supply contract (FOR SAWMILL)
- Description of industry/Feasibility Study/Engineer’s Information Report as to type and volume of raw materials
used, products manufacture or to be stored; average production output/capacity; industry wastes, and
employment size.
- Flow Manufacturing Process/diagram/chart
- Environmental Compliance Certificate (ECC) from EMB-DENR
- Affidavit of non-objection from neighbors, if project in non-conforming with the zone within _____________
- Endorsement of the project by the Barangay Council
- Endorsement of the Local Government Unit ( SB)
