INO FEES REQUIRED FOR THE FILING AND EVALUATION OF CSHP Revised Form: CSHP Form 14-2023: Date of Revision. 90 Api 2023, Page ot [~-A ‘APPLICATION FORM PO Department of Labor and Employment FOR THE EVALUATION/PROCESSING OF REGIONAL OFFICE NO. ‘CONSTRUCTION SAFETY & HEALTH - PROGRAM (CSHP) Legal Bases: ‘Type of Construction Project: 1, Presidential Decree No, 442, as renumbered __DPWH project Lee rica er ok Sereno 2018 —s£ Other Publcprivate construction project | Deane (LGUs, other gov offices, private erties) Residential projact engaging the services of ‘a construction frm Instructions This fom shall be duly accomplished and submitied ‘by the MAINIGENERAL CONTRACTORISUBCONTRACTORIBUILDING OWNER in applying fora Construction Safety and Health Program intended for a specifi construction project. Note: THE CHECKLIST OF REQUIREMENTS shell be used in receiving the application. Only applications with ‘compete requirements and attachments wil be processed. ‘A. Company Profile/License/Registration of Main/General Contractor Complete Name of he Company/Main’ | Complete Address ofthe Project ‘General ContracorProject Owner PLAZA DE ROXAS, BARANGAY 2, NASUGBU, QUINI SQUARE CONSTRUCTION] BATANGAS | AND SUPPLY ial Eulalia R. Quiniqui General Manager Tel, No; 09688912433 Fax No. Name of Project ManageriOwner! Tel. No | Contact Person Ema Municipality of Nasugbu, Batangas, (09658912433 ‘Contractors PCABIJV License No: ‘Number of workers: . | 24085, Male: 30 Female: 02 Total t | Date of Vality: 21NOV2026 | -22_ Total employment: _32 3 Engaged Subcontractors’ Profile ; i ‘Name of Sub-contractors Scope of Work and No. of Workers | PCAB | Dateof | Date of DOLE ((fany) | Project Cost License | Validity | Registration - 3 = | 4 | | : : _ | 5 - - (Use separate sheet, if necessary)- ‘APPLICATION FORM Department of Labor and Employment FOR THE EVALUATION/PROCESSING OF REGIONAL OFFICE NO. CONSTRUCTION SAFETY & HEALTH | PROGRAM (CSHP) eed Ree sees are B. Project Profile "Name of the Project: (Please attach copy of Notice of Award or Notice to Proceed or oer documents indicating name and deals ofthe provect) See attached files for your references ‘Complete Project Address/Location: PLAZA DE ROXAS, BARANGAY 2, NASUGBU, BATANGAS. Name of Project Owner: ah Tel, No: 09658912433 Municipality of Nasugbu, Batangns (09658912433 | Fax No: | email; | Project Classification Estimated No. of Workers to be | Dale of Estimated StarvExecution of the Consteection deployed inthe project: project: Eight - 08 DEC. j 11) 2023 ‘Month ‘Day Year (Workforce of the project to Total Project include workers of the sub- | Duration ofthe project (Ps. state the number Cost:_Php 498,000.00 ‘ontractors) ‘of calendar days). Forty-Five (45) | Brief Description of ActivieshWork Flow (Please attach adltional sheet, necessary) Project Billboard; Construction Safety and Health Program; Structure Excavatior Reinforced Concrete; Reinforcing Steel Bar Deformed; Formworks & False Wark; tee! thor zed, ent even Form C36 Farm 1202 =Deo Rovio: 30 An 2008 [APPLICATION FORM Department of labor and Employment FOR THE EVALUATIONIPROCESSING OF REGIONAL OFFICE NO. _ CONSTRUCTION SAFETY & HEALTH \ PROGRAM (CSHP) (OSH Personnel assigned to the project Designated Safely Offcers: Designated Fist Aide: Name Date of | ‘Name Date of training | training |_Enge. Sharmaine R.Quiniguini 151 Nicolas E. Cardinal ‘O9sUN23, eee | (Pease attach photocopy of Certificate of Completion on the Basic ‘OSH Course for Construction Ste Safety Officers issued by DOLE- | BWC accreted Safety Training Organtzatons or recognized | insttution) Please attach photocopy of te Certfcate of FirstAd Training ad vai First Ai 1D from Phi Red Cross, DOH, ‘Bureau of Fre and DOLE- Accredited TVIs with TESOA registered EMS and cther DOLE-Accredted frst training provider — Other OH personnel (if more than 50 workers will be deployed in the project) Name Date ofrquired BOSH Training OH Nurse 7 ‘OH Physician Dentist | (iF Heavy Equipment wil be used inthe Project) {ist of heavy equipment to be used in the Project: 4 2 3. 4 5. (Please attach additional sheet, i{ necessary) Educational necessary) ____| (Attach photocopy of skils cetficalion from TESDA — jee Profile ofthe person who prepared the CSH Program forthe abovementioned Project | CIVIL ENGINEER _ Work Experisnoe in OSH: TWO (02) yrs. ‘Other Qualifcati | THEREBY CERTIFY ON MY HONOR TO THE TRUTHF! COMPANY HEREBY COMMITS TO STRICTLY IMPI HEALTH PROGRAM DESIGNED FOR THE ABOVEM: LEMENT {ENTIONE! Submitted By 0 ‘ULNESS OF THE ABOVEMENTIONED INFORMATION, THE | one: THE ATTACHED CONSTRUCTION SAFETY AND =D PROJECT. Mrs. Ful iniquini General Manager 27NOV2023 | | Sionature Over Pfhited Name ofthe Position Date | tractor | ‘Assigned Evaluator | HEREBY CERTIFY THAT UPON EVALUATION, ALL DOCUMENTS ARE CORRECT AND COMPLETE BASED ON’ ‘THE DOLE PRESCRIBED CHECKLIST. Evaluated By ] | Sianature Over Printed Name Se _|