Dole Application. Form

NO FEES REQUIREDFOR 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:
Main /General Contractor 0792 F. Manalo cor. J. Pueblo St., Brgy. Bambang, Pasig
City
ST. GERRARD CONST. GEN
Tel. No:
CONTRACTOR & DEV. Corp. (Joint
Venture) MCP ENTERPRISE & GEN. Fax No.
CONTRACTOR INC./ A. DELA CRUZ
BUILDERS INC.
Name of Project Manager/ Contact Person: Email:
PACIFICO F. DISCAYA
Main Contractor PCAB License No.31762 Main Contractor Total employment 20

Male 27 Female 0
Date of Validity; June 30, 2023
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). __________________ __________
b. per Rule 1020, OSHS (onetime registration). _________________ __________

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
2.
3.
4.
5.
REVISED APPLICATION FORM for
Department of Labor and Employment EVALUATION/ APPROVAL OF
REGIONAL OFFICE NO. NCR CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
(Use separate sheet, if necessary)

B. Project Profile/Description
Name of the Project: (Please attach copy of Invitation to Bid/other documents indicating name and details of the
project)
PROPOSED CONSTRUCTION OF HOUSING 32 – BALINGASA HIGH RISE HOUSING

(PHASE 1A) @ BRGY. BALINGASA, DIST. 1, QUEZON CITY
ID NO: 22-00074
Complete Project Address/Location
BRGY. BALINGASA, DIST. 1, QUEZON CITY
Name of Project Owner

QUEZON CITY LOCAL GOVERNMENT UNIT Tel. No: _____________
Fax No: _____________
Email: _____________
Project Classification: Date of Estimated Start/Execution of

Estimated No. of Workers to the project
GENERAL ENGINEERING be deployed in the project:
MARCH 23 2022
27 WORKERS Month Day Year
(Workforce of the project to Duration of the project (Pls. state the

Total Project Cost: P453,991,306.23 include workers of the sub- number of calendar days
contractor/s)
510 Calendar Days
Brief Description of Activities/Work Flow (You may attach additional sheet, if necessary)
PROPOSED CONSTRUCTION OF HOUSING 32 – BALINGASA HIGH RISE HOUSING
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. IV-A CONSTRUCTION SAFETY AND HEALTH PROGRAM
OSH Personnel assigned to the project
Name of Appointed Safety Officer/s: Name of Appointed First-Aider/s:
Date of his/her BOSH training: OCT. 21-24, 2014 Date of First –Aid Training: OCT. 21-24, 2014
(Pls. attach photo copy of Certificate of Completion on the Validity of ID:

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
OH Physician
Dentist
(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)
- Backhoe,
- Dump truck
- Breaker
Profile of the person who prepared the CSH Program for the abovementioned Project:
Name and Signature Educational Background:
BSCE
Work Experience in OSH:
PACIFICO F. DISCAYA 5 YEARS
Signature over printed name
Other Qualifications:
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 HEALTHPROGRAM DESIGNED FOR THE ABOVEMENTIONED PROJECT.
Submitted By:
PACIFICO F. DISCAYA
Signature Over Printed Name
Position: Authorized Managing Officer
Date: _______________
Revised Form.: CSHP-DO 13-98

Date of Revision: June1, 2011
Page 3 of 3

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NO FEES REQUIREDFOR THE FILING, EVALAUTION AND APPROVAL OF CSHP

Revised Form.: CSHP-DO13-98:

REVISED APPLICATION FORM for

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

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

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

Main Contractor PCAB License No.31762 Main Contractor Total employment 20

b. per Rule 1020, OSHS (onetime registration). _________________ __________

(Use separate sheet, if necessary)

PROPOSED CONSTRUCTION OF HOUSING 32 – BALINGASA HIGH RISE HOUSING

BRGY. BALINGASA, DIST. 1, QUEZON CITY

Name of Project Owner

Fax No: _____________

Project Classification: Date of Estimated Start/Execution of

(Workforce of the project to Duration of the project (Pls. state the

PROPOSED CONSTRUCTION OF HOUSING 32 – BALINGASA HIGH RISE HOUSING

Revised Form.: CSHP-DO 13-98

OSH Personnel assigned to the project

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

(Pls. attach photo copy of Certificate of Completion on the Validity of ID:

(If Heavy Equipment will be used in the Project)

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

Position: Authorized Managing Officer

Revised Form.: CSHP-DO 13-98

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b. per Rule 1020, OSHS (onetime registration). _______