Scribd Logo
Upload

Welcome to Scribd!

  • 38 views

    G2776 PM NCR 03.08 F.03 Form1A CSHP Application Form

    Uploaded by

    deanne.cse

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    G2776 PM NCR 03.08 F.03 Form1A CSHP Application Form

    Uploaded by

    deanne.cse
    38 views4 pages

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    38 views4 pages

    G2776 PM NCR 03.08 F.03 Form1A CSHP Application Form

    Uploaded by

    deanne.cse

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

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

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


    Contact Person: Email: [email protected]
    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 :
    [email protected]

    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

    You might also like