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Dole CSHP Application Form for Residential Projects

This document is an application for a Construction Safety and Health Program for a proposed 2-storey residential project located in Trinidad Village, Bacolor, Pampanga. The project is estimated to last 8 months with 12 workers and cost less than 3 million pesos. The project owners, April Anne A. Puno and Fritz Roy A. Puno, commit to complying with occupational safety and health standards and guidelines for construction projects and to implementing a construction safety and health program for this project. They also acknowledge their responsibility to provide appropriate personal protective equipment and safety training to workers.

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136 views2 pages

Dole CSHP Application Form for Residential Projects

This document is an application for a Construction Safety and Health Program for a proposed 2-storey residential project located in Trinidad Village, Bacolor, Pampanga. The project is estimated to last 8 months with 12 workers and cost less than 3 million pesos. The project owners, April Anne A. Puno and Fritz Roy A. Puno, commit to complying with occupational safety and health standards and guidelines for construction projects and to implementing a construction safety and health program for this project. They also acknowledge their responsibility to provide appropriate personal protective equipment and safety training to workers.

Uploaded by

jazzygameseu
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd

Form Reference No: PM-NCR-03.08-F-03.

R01
Regional Office: DOLE-REGION 3
Application No: ________

Application for
CONSTRUCTION SAFETY AND HEALTH PROGRAM (CSHP)
(Intended only for residential project/s (2 storey and below) or minor repair works with 15 workers or less or with
project cost of less than Php3,000,000.00.)

Project Name: __Proposed 2-Storey Residence __________________________________________


Project Complete Address/Location: _Lot 10 Blk 20, Macopa St., Trinidad Village, Bacolor, Pampanga_______
_________________________________________________________________________________________
Project Duration: ___8 months___ Project Start: __January 2020__ Completion Date: _August 2020______
(No. of Calendar days) (Date of estimated start) (Date of project completion)
Estimated Project Cost: ______________________ Number of Workers: __12___________________
Name of Contractor (if any):____Admin__________________________________________________________
Contractor’s Address: ________________________________________________________________________
____________________________________________________________ Fax No.:_______________________
PCAB License No.______________ Date of Validity: ____________ Email address: _______________________

Name of Project Owner: April Anne A. Puno and Fritz Roy A. Puno_ Fax No.:_____________________
Project Owner Address: _ Lot 10 Blk 20, Macopa St., Trinidad Village, Bacolor, Pampanga__________________
______________________________________________________ Email address: ____________________

Accomplished by: April Anne A. Puno and Fritz Roy A. Puno


Signature over Printed Name
of
OWNER / CONTRACTOR
**********************************************************************
COMMITMENT TO COMPLY on OSH

I/We ___ April Anne A. Puno _____ and ___ Fritz Roy A. Puno __________________
(Name of Contractor’s Authorized Official and/or Project Owner)

do hereby commit and bind ourself to comply with the applicable provisions of the
Occupational Safety and Health Standards (OSHS) and Department Order No.13 series
of 1998 – Guidelines Governing Occupational Safety and Health in the Construction
Industry. I/We hereby commit to implement a suitable Construction Safety and Health
Program designed for the abovementioned project. I/We also acknowledge my/our
responsibilities to provide the appropriate Personal Protective Equipment (PPE) and job
safety and health instructions and training to all our workers during the duration of the
project.

__April Anne A. Puno and Fritz Roy A. Puno__ ___________________________________


PROJECT OWNER CONTRACTOR
Signature Over Printed Name Signature Over Printed Name

(NOTE: NO FEES REQUIRED FOR APPLICATION, PROCESSING AND APPROVAL OF CSHP)

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