Certification For Projects To Be Undertaken by Administration

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SuSd.1.I.

009
Rev. 00, 22 Feb. 2010

Certification for Projects to be Undertaken by Administration

1. That (I), _____________________ with (License No.)____________________ will be responsible for


the implementation and completion of the ___________________________________________.

2. That in doing so, ____________________________________ will secure the services of the following
engineers and workers for the said project.

3. That said project will be under the direct supervision and responsibility of the following engineers:

For Architectural Works: ______________________________ P.R.C. License No.: ____________

For Civil Works: ______________________________ P.R.C. License No.: ____________

For Sanitary Works: ______________________________ P.R.C. License No.: ____________

For Electrical Works: ______________________________ P.R.C. License No.: ____________

4. That I commit to provide a duly trained Project Safety Officer and provide all workers with Personal
Protective Equipment (PPE) and shall provide a Construction Safety and Health Program to be
implemented.

Project Safety Officer: ___________________ _________________________

5. That I, ____________________________, _______________, am executing this Affidavit for the


purpose of applying for the necessary permits for the said project under the PD 1096 National Building
Code of the Philippines and RA 4566.

Acknowledged by:
Name: Signature

For Civil Works: Engr. ___________________ ___________________________


P.R.C. License No.: __________

For Sanitary Works: Engr. ___________________ ___________________________


P.R.C. License No.: __________

For Electrical Works: Engr. ___________________ ___________________________


P.R.C. License No.: __________

IN WITNESS WHEREOFF, I have hereunto set my hand this ___ day of __________at
________________________.

_____________________________________
Signature of Affiant

SUBSCRIBED AND SWORN, before me this ___ day of _____________at ________________, affiant
exhibiting to me her Community Tax Certificate No.___________ issued on ___________ at
________________.

Doc. No.:
Page No.:
Book No.:
Series of 2019

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