AFFIDAVIT

I, RODEL RUTAGINES_ Filipino, of legal age and a resident of Brgy. Binonoan, Infanta, Quezon_,

after having been sworn in accordance with law herby depose and say;

1. That I am the owner of lot consisting an area of_ Under Certificate of Title No.

___________________ _______________ located at Brgy. Binonoan, Infanta, Quezon;

2. That the said lot is intended for the construction of _One-Storey Residence which is of

personal property and will be constructed by administration;

3. That the construction is not intended for sale, lease, commercial/industrial use or any

other income generating purpose;

4. That I execute this affidavit for compliance with Department of Labor and Employment

(DOLE) in connection for Construction Safety and Health Program (CSHP) Residential

Application.

5. That I, declare penalty of perjury that the forgoing is true and correct.

Further Affiant sayeth non.

WHEREOF, I have hereunto affixed my signature this _____ day of __________, __________ at

______________________________________________________________.

________________________________
(Signature of Affiant over Printed Name)