NO FEES REQUIRED FOR THE FILING AND EVALUATION OF CSHP

Revised Form: CSHP Form 1A-2023: PM-NCR-03.08-F.03

Date of Revision: 30 April 2023 Page 1 of 3
APPLICATION FORM
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
2. Republic Act No. 11058 ✓ Other Public/private construction project
3. Department Order No. 198, Series of 2018
(LGUs, other gov’t offices, private entities)
_____ Residential project engaging the services of
a construction firm
Instructions: This form shall be duly accomplished and submitted by the MAIN/GENERAL
CONTRACTOR/SUBCONTRACTOR/BUILDING OWNER in applying for a Construction Safety and Health Program
intended for a specific construction project.

Note: THE CHECKLIST OF REQUIREMENTS shall be used in receiving the application. Only applications with
complete requirements and attachments will be processed.

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

Complete Name of the Company/Main/
General Contractor/Project Owner:
CNZ CONSTRUCTION CORP.
Complete Address of the Project:
2201 Rombloon St. cor. Blumentrit Ext. Sampaloc, Manila
Tel. No: __________________________________________________
Fax No. ___________________________________________________

Name of Project Manager/Owner/ Tel. No: 7358-2426 / 09562816842

Contact Person: Email: deanne.cnz@gmail.com
WILLARD CARLOS

Contractor’s PCAB/JV License No: Number of workers:

35576
Male: __9___ Female: __0___ Total employment: __9__
Date of Validity: 02/07/2026
Engaged Subcontractors’ Profile

Name of Sub-contractors Scope of Work and No. of Workers PCAB Date of Date of DOLE
(If any) Project Cost License Validity Registration

1. CNZ Construction Corp. Contract, Permitting 9 35776 02/07/26

and Construction
2.

3.

4.

5.

6.

7.

(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)

B. Project Profile/Description
Name of the Project: (Please attach copy of Notice of Award or Notice to Proceed or other documents indicating
name and details of the project)
BUILD TO SUIT PROJECT/ Installation of 12M Bipod Tower

Complete Project Address/Location:

2060 Kahilom 1, Brgy. 867, Zone 095, Pandacan Manila

Name of Project Owner: Tel. No: _____________

EDGEPOINT TOWERS, INC. Fax No: _____________

Email :
aldin.aliuddin@edgepointinfra.com

Project Classification: Estimated No. of Workers to be Date of Estimated Start/Execution of the

deployed in the project: project:

Nine (9) ____08____/___05_____/__2024____

Month Day Year
(Workforce of the project to
Total Project Cost: include workers of the sub- Duration of the project (Pls. state the number
Php 291,700.00 contractor/s) of calendar days)
___________________________
 APPLICATION FORM
Department of Labor and Employment FOR THE EVALUATION/PROCESSING OF
REGIONAL OFFICE NO. ________ CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
Brief Description of Activities/Work Flow (Please attach additional sheet, if necessary):

Installation of 12M Bipod Tower of Edgepoint Towers, Inc.

- Mobilization
- Lay out
- Delivery and Hauling of Materials
- Installation of Bipod Poles and Constructionof Out door Pad
- Electrical Installation
- Cable Ladder Installation
- Grounding Installation
- RFTI
- Pre Acceptance
- Final Acceptance

Revised Form: CSHP Form 1A-2023 Page 2 of 3

PM-NCR-03.08-F.03A.R02
Date of Revision: 30 April 2023
APPLICATION FORM
Department of labor and Employment FOR THE EVALUATION/PROCESSING OF
REGIONAL OFFICE NO. ______ CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
OSH Personnel assigned to the project
Designated Safety Officers: Designated First Aider:

Name Date of Name Date of ID

training training Validity
Froilan M. Ballesteros Aug. 8-11, 2023 Carlo James Enriquez June 25-28,2024

Please attach a photocopy of the Certificate of First-Aid

(Please attach photocopy of Certificate of Completion on the Basic Training and valid First Aid ID from Phil Red Cross, DOH,
OSH Course for Construction Site Safety Officers issued by DOLE- Bureau of Fire and DOLE- Accredited TVIs with TESDA
BWC accredited Safety Training Organizations or recognized registered EMS and other DOLE-Accredited first aid training
institution) provider
Other OH personnel (if more than 50 workers will be deployed in the project)
Name Date of required BOSH Training
OH Nurse N/A N/A
OH Physician N/A N/A
Dentist N/A N/A
(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:
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
(Please attach additional sheet, if necessary.) (Attach photocopy of skills certification from TESDA.)
Profile of the person who prepared the CSH Program for the abovementioned Project
Educational Background:
College Graduate
Work Experience in OSH:
ELISA REYLLO N/A
Signature over printed name Other Qualifications:
N/A
I HEREBY CERTIFY ON MY HONOR TO THE TRUTHFULNESS OF THE ABOVEMENTIONED INFORMATION. THE
COMPANY HEREBY COMMITS TO STRICTLY IMPLEMENT THE ATTACHED CONSTRUCTION SAFETY AND
HEALTH PROGRAM DESIGNED FOR THE ABOVEMENTIONED PROJECT.

Submitted By:
JOCELYN M. ENRIQUEZ
President
CNZ Construction Corp.
Signature Over Printed Name of the Position Date
Owner/Contractor
Assigned Evaluator
I HEREBY CERTIFY THAT UPON EVALUATION, ALL DOCUMENTS ARE CORRECT AND COMPLETE BASED ON
THE DOLE PRESCRIBED CHECKLIST.
Evaluated By:

Signature Over Printed Name Position Date