Srs Form-02-2021-00

SRS Form-02-2021-00
Republic of the Philippines

Department of Transportation
MARITIME INDUSTRY AUTHORITY
Regional Office VII
Cebu City
APPLICATION FORM
□ Authority to Acquire Vessel thru Local Construction □ Load Line Certificate
□ Shipbuilding Permit □ Certificate of Stability/ Intact Stability booklet Approval/ Supervision of
□ Boatbuilding Permit Inclining Experiment
□ Periodical Survey 1st 2nd 3rd 4th □ Approval of Damage Stability Booklet
□ Construction Certificate □ Cargo Securing Manual Compliance Certificate
□ Tonnage Measurement Certificate □ Shipbreaking Permit
□ Inspection for BUCUS release
COMPANY INFORMATION
Name of Company/Owner
Principal Address Telephone/Cellphone No.
Contact Person Position Designation
VESSEL INFORMATION
Name of Vessel
Gross Tonnage Net Tonnage Length Breadth Depth
Ship Type Official No. Engine Class Society
Kilowatt
Vessel Location for Survey/Inspection: Availability Dates for Survey/Inspection :
□ SHIPBUILDING / BOATBUILDING PERMIT (MC 2018-02/2015-09)

□ Letter of Intent/Request □ Vessel Name Clearance
□ Notarized Memorandum of Agreement (MOA) or □ General Arrangement Plan
Shipbuilding/Boatbuilding Contract □ Quotation for machinery/ship and breakdown of cost
□ PERIODICAL SURVEY (MC 2015-07) 1st 2nd 3rd 4th
□ Letter of Request □ Vessel Plans Approval □ Authority to Acquire Approval
□ CONSTRUCTION CERTIFICATE (MC 2015-07)
□ Letter of Request
□ Certification/Attestation from Class Societies that the vessel was constructed according to their rules and regulations, if applicable
□ Notarized Builder’s Certificate
□ TONNAGE MEASUREMENT CERTIFICATE (MC 2007-04)
New Building Re-issuance
□ Letter of Request □ Latest Photograph of Vessel □ Letter of Request indicating reason for re-issuance
□ Duly notarized Builder’s Certificate □ Stencil/Engine Receipt □ Previous Tonnage Measurement Certificate (original)
□ Duly notarized Affidavit of Ownership □ Duly notarized Affidavit of No Alteration
□ Letter of Approval of Vessel Plans □ Stencil (for change of engine)
□ LOAD LINE CERTIFICATE (MC 2007-03)
New Issuance Renewal/Endorsement
□ Letter of Request □ CO/CPR □ Letter of Request
□ Approved copy of General Arrangement Plan, Lines Drawing, □ Load Line Certificate
Midship section, longitudinal hull girder strength calculation and □ Copy of Stability Certificate
Hydrostatic Curves
□ CERTIFICATE OF INTACT STABILITY (MC 2007-05)
New Issuance Endorsement Supervision of Inclining Experiment
□ Letter of Request □ Letter of Request □ Letter of Request
□ CO/CPR □ Copy of approved Booklet/last 2 drydocking certificates □ Inclining Test Procedure
□ Stability Booklet (3 copies) □ Copy of Stability and Load Line Certificate □ Notification
□ APPROVAL OF DAMAGE STABILITY BOOKLET (MC 2015-08)
□ Letter of Request □ Load Line Certificate □ CO/CPR
□ Damage Stability Booklet (3 copies) □ Certificate of Intact Stability
□ CARGO SECURING MANUAL COMPLIANCE CERTIFICATE /ENDORSEMENT (MC 2011-03)
□ Letter of Request □ Load Line Certificate □ CSM Manual (3 sets/copies) □ CO/CPR
□ INSPECTION FOR BUCUS RELEASE (MC 104)
□ Letter of Intent/Request □ Copy of Authority to Import
□ SHIPBREAKING PERMIT (MC 2013-02)
□ Letter of Intent/Request □ Notarized Board Resolution/Secretary’s Certificate/SPA
□ Notarized Memorandum of Agreement (MOA) or authorizing the filing of the application and designating
Shipbreaking Contract between owner & shipbreaker officials/authorized representative to sign in behalf of the
□ MARINA registration/license of shipbreaker applicant-company
□ Certificate of Inventory of Hazardous Materials □ Certificate from PCG, LGU and DENR
□ Certificate of deletion or Shipbreaking/ Ship Recycling plan and purchase contract
□ Approved Ship-specific Shipbreaking/Ship Recycling plan
Name and Signature of Applicant/Authorized Designation/Position

Representative
Screened and ATAP issued by Date
Cashier O.R. No. Amount Date
SRS Form-02-2021-00

Srs Form-02-2021-00 - Bucus, TMC, LLC, Cos, CSMCC, DSB

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Srs Form-02-2021-00 - Bucus, TMC, LLC, Cos, CSMCC, DSB

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Republic of the Philippines

□ SHIPBUILDING / BOATBUILDING PERMIT (MC 2018-02/2015-09)

Name and Signature of Applicant/Authorized Designation/Position

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