Regional Office: DOLE-NCR

Application No: ________

Application for
CONSTRUCTION SAFETY AND HEALTH PROGRAM (CSHP)
(Intended only for residential project/s (2 storey and below) or minor repair works with less than 10 workers.)

17JA0023- REPAIR/IMPROVEMENT OF SINUNUC SHORELINE PROTECTION, SINUNUC,

ZAMBOANGA CITY
Project Name: ______________________________________________________________________
SINUNUC, ZAMBOANGA CITY
Project Complete Address/Location: ___________________________________________________________
_________________________________________________________________________________________
Project Duration: _____________
298 CAL.DAYS Project Start: ________________
02-25-2017 Completion Date: _________________
12-23-2017
(No. of Calendar days) (Date of estimated start) (Date of project completion)
Php 13,604,250.00
Estimated Project Cost: ______________________ Number of Workers: _______________________
30

LONG ISLAND BUILDERS AND CONSTRUCTION

Name of Contractor (if any):___________________________________________________________________
Contractors Address: ________________________________________________________________________
QUIRINO ST., DON ANDRES, IPIL, ZAMBOANGA SIBUGAY
(062) 333-2515
____________________________________________________________ Fax No.:_______________________
31730
PCAB License No.______________ Date of Validity: ____________
June 30, 2017 Email address: _______________________
longisland_bc05@yahoo.com

DPWH - ZC
Name of Project Owner: __________________________________ Fax No.:_____________________
ZAMBOANGA CITY
Project Owner Address: ______________________________________________________________________
______________________________________________________ Email address: ____________________

Accomplished by: DEXTER W. TSANG

____________________________________
Signature over Printed Name
of
OWNER / CONTRACTOR
**********************************************************************

COMMITMENT TO COMPLY on OSH

I/We Long
__________________________________
Island Builders and Construction and _________________________________
DPWH - ZC
(Name of Contractors Authorized Official and/or Project Owner)
do hereby commit and bind ourself 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.

_____________________________________
CHOLIE M. ROBLE ___________________________________
DEXTER W. TSANG
PROJECT OWNER CONTRACTOR
Signature Over Printed Name Signature Over Printed Name

(NOTE: NO FEES REQUIRED FOR APPLICATION, PROCESSING AND APPROVAL OF CSHP)