Form Reference No: PM-NCR-03.08-F-03.
R02
Regional Office: DOLE-NCR
Application No: A-1440-03-12-RO69-0005
Application for
CONSTRUCTION SAFETY AND HEALTH PROGRAM (CSHP)
Project Name: ____Proposed 2- Storey Residential Unit____
Project Complete Address/Location: ___________________________________________________________
_________________________________________________________________________________________
Project Duration: _____________ Project Start: ________________ Completion Date: _________________
(No. of Calendar days) (Date of estimated start) (Date of project completion)
Estimated Project Cost: ______________________ Number of Workers: _______________________
Name of Contractor (if any):___________________________________________________________________
Contractor’s Address: ________________________________________________________________________
____________________________________________________________ Fax No.:_______________________
PCAB License No.______________ Date of Validity: ____________ Email address: _______________________
Name of Project Owner: __________________________________ Fax No.:_____________________
Project Owner Address: ______________________________________________________________________
______________________________________________________ Email address: ____________________
Accomplished by: ______________________________________________
Signature over Printed Name of OWNER / CONTRACTOR
**********************************************************************
COMMITMENT TO COMPLY on OSH
I/We _________________SPACE_________ and _____Engr
(Name of Contractor’s Authorized Official and/or Project Owner)
do hereby commit and bind our self to comply with the applicable
provisions of the Occupational Safety and Health Standards
(OSHS) and Department Order No.13 series of 1998 – Guidelines
Governing Occupational Safety and Health in the Construction
Industry. I/We hereby commit to implement a suitable
Construction Safety and Health Program designed for the
abovementioned project. I/We also acknowledge my/our
responsibilities to provide the appropriate Personal Protective
Equipment (PPE) and job safety and health instructions and
training to all our workers during the duration of the project.
_____________________________________
___________________________________
PROJECT OWNER CONTRACTOR
Signature Over Printed Name Signature
Over Printed Name
