Form Reference No: PM-NCR-03.

08-F-04

NO FEES REQUIRED FOR THE FILING , EVALAUTION AND APPROVAL OF CSHP

Revised Form.: CSHP-DO13-98:
Date of Revision : June1, 2011 Page 1of 3

REVISED APPLICATION FORM for

Department of Labor and Employment EVALUATION/ APPROVAL OF
REGIONAL OFFICE NO. _NCR_ CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)

Legal Basis: Section 5 of Department Order No. 13 s 1998

(Guidelines Governing Occupational Safety and Health In Construction Industry)

Instructions: This form shall be duly accomplished and submitted by the MAIN/GENERAL
CONTRACTOR in applying for an approval of a Construction Safety and Health Program intended for
a specific construction project.

Note: A CHECKLIST OF REQUIREMENTS shall be used in receiving the application.

Only an application form with a complete requirements and attachments will be processed.
Application found with incomplete requirements will be given 15 calendar days to comply. Failure to
comply within the prescribed period, the application will be deemed disapproved.

A. Company Profile/License/Registration of Main/General Contractor

Complete Name of the Company/ Complete Address: N/A
Main /General Contractor
Tel. No: N/A
BY ADMINISTRATION
Fax No. N/A
Name of Project Manager/Contact Person: Email: N/A
N/A

Main Contractor PCAB License No._ N/A Main Contractor Total employment _ N/A ____
_________ Male _ N/A ____ Female _ N/A ____

Date of Validity:_______________________
DOLE Registration of Main Contractor ( Pls. attach photo copy of Registration forms received and approved by
the concerned DOLE Regional Office)
Date Registered/Approved DOLE-RO
a. per DO 18-02 ( requires yearly renewal) ______N/A__________ __ N/A _

b. per Rule 1020, OSHS (one time registration) _____ N/A _________ ___N/A _____
Sub-contractors’ Profile/License
No. of PCAB Validity Date of
Name of Sub-contractors (If , any) Scope of Work and Workers License Date DOLE
Project Cost Registration
1. N/A N/A N/A N/A N/A N/A

2.

3.

4.

5.

(Use separate sheet , if necessary)

B. Project Profile/Description
 REVISED APPLICATION FORM for
Department of Labor and Employment EVALUATION/ APPROVAL OF
REGIONAL OFFICE NO. _NCR_ CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)

Name of the Project: (Please attach copy of Invitation to Bid/other documents indicating name and details of the
project)

Proposed Two(2 )- Storey Residential Building

Complete Project Address/Location

312 M.H. Del Pilar Street, Maysilo, Malabon City

Name of Project Owner

Tel. No: 82779027

IRENE V. SYJUCO-CHAOUI Fax No: _____________

Email : _____________

Project Classification: Date of Estimated Start/Execution of

Estimated No. of Workers to the project:
GENERAL BUILDING be deployed in the project: __AUGUST 01, 2022____
Month Day Year
_______10____________
Duration of the project (Pls.
Total Project Cost:_Php 4.974 Million_ (Workforce of the project to state the number of calendar days
include workers of the sub-
contractor/s) 300 CALENDAR DAYS

Brief Description of Activities/Work Flow (You may attach additional sheet, if necessary)
- EXCAVATION WORKS
- STRUCTURAL AND REBAR WORKS
- CONCRETING WORKS
- FORM WORKS
- MASONRY WORKS
- SCAFFOLDS (TEMPORARY STRUCTURES)
- CARPENTRY WORKS
- ELECTRICAL WORKS
- SANITARY AND PLUMBING WORKS
- GAS, CUTTING AND ELECTRIC WELDING OPERATIONS
- PAINTING WORKS
- TILE WORKS
- GLASS AND ALUMINUM WORKS

Revised Form.: CSHP-DO 13-98

Date of Revision: June1, 2011 Page 2of 3
 Department of labor and Employment APPLICATION FORM for APPROVAL OF
REGIONAL OFFICE NO. _NCR_ CONSTRUCTION SAFETY AND HEALTH PROGRAM

OSH Personnel assigned to the project

Name of Appointed Safety Officer/s: Name of Appointed First-Aider/s:

________N/A____________________________ ____________N/A_____________________

Date of his/her COSH training: ______N/A_________ Date of First –Aid Training:

(Pls. attach photo copy of Certificate of Completion on the Validity of ID: ___N/A_______
Basic OSH Course for Construction Site Safety Officers issued
by DOLE-BWC accredited Safety Training Organizations or (Pls. attach photo copy of Certificate of First-Aid Training
recognized institutions) and Valid First Aider ID from PNRC

Other OH personnel (if more than 50 workers will be deployed in the project)
Name Date of BOSH Training
OH Nurse N/A
N/A
OH Physician N/A
N/A
Dentist N/A N/A

(If Heavy Equipment will be used in the Project)

List of Heavy Equipment to be Used in the Project Name of Heavy Equipment Operator/s (To attach photo
(Please attach additional sheet, if necessary) copy of skills certification from TESDA)

N/A N/A

Profile of the person who prepared the CSH Program for the abovementioned Project:
Name and Signature Educational Background:
College Graduate
Work Experience in OSH:

MARTIN EMMANUEL V. SYJUCO Other Qualifications:

Signature over printed name

I HEREBY CERTIFY ON MY HONOR TO THE TRUTHFULLNESS OF THE ABOVEMENTIONED

INFORMATION. THE COMPANY HEREBY COMMIT TO STRICTLY IMPLEMENT THE ATTACHED
CONSTRUCTION SAFETY and HEALTH PROGRAM DESIGNED FOR THE ABOVEMENTIONED PROJECT.

Submitted By:

Signature Over Printed Name: IRENE V. SYJUCO-CHAOUI______________

Position: OWNER_______________________________________________

Date: JULY 13, 2022_______________________________________

Revised Form.: CSHP-DO 13-98

Date of Revision: June1, 2011 Page 3 of 3