Revised Form.
CSHP-DO13-98:
Date of Revision: June1, 2011
Page 1of 3
REVISED APPLICATION FORM for
Department of Labor and EVALUATION/ APPROVAL OF
Employment CONSTRUCTION SAFETY & HEALTH PROGRAM
REGIONAL OFFICE NO. 6 (CSHP)
Legal Basis: Section 5 of Department Order No. 13 s 1998
(Guidelines Governing Occupational Safety and Health In Construction
Industry)
Instructions: This form shall be duly accomplished and submitted by the MAIN/GENERAL
CONTRACTOR in applying for an approval of a Construction Safety and Health Program
intended for a specific construction project.
Note: A CHECKLIST OF REQUIREMENTS shall be used in receiving the application.
Only an application form with a complete requirements and attachments will be processed.
Application found with incomplete requirements will be given 15 calendar days to
comply. Failure to comply within the prescribed period, the application will be deemed
disapproved.
A. Company Profile/License/Registration of Main/General Contractor
Complete Name of the Company/ Complete Address: Blk.32 Lot.11 Josefina
Main /General Contractor Street.,Eroreco,Brgy. Mandalagan,Bacolod City
CUBIXX13 BUILDERS
Tel. No: (034) 458-8443
CORPORATION
Fax No.
Name of Project Email:
Manager/Contact Person: Jean cubixx13Corp@[Link]
Paul Alexander B. Ortega
Main Contractor PCAB License Main Contractor Total employment 6
No. 47414 Male 3 Female 3
Date of Validity: June 30, 2022
DOLE Registration of Main Contractor ( Pls. attach photo copy of Registration forms received and
approved by the concerned DOLE Regional Office)
Date Registered/Approved DOLE-
RO
a. per DO 18-02 ( requires yearly renewal) __________________
__________
b. per Rule 1020, OSHS (one time registration) __________________
___________
Sub-contractors’ Profile/License
No. of PCAB Validity Date Date of DOLE
Name of Sub- Scope of Work Workers License Registration
contractors (If , any) and Project
Cost
1. N/A
2. N/A
3. N/A
4. N/A
5. N/A
(Use separate sheet , if necessary)
B. Project Profile/Description
Name of the Project: (Please attach copy of Invitation to Bid/other documents indicating name and
details of the project)
Concrete Paving of JCT National Highway To So. Mambocano Road, Rural Access
(Road Upgrading)
Complete Project Address/Location :
Brgy. Cabatangan, Talisay City, Negros Occidental
Name of Project Owner
Tel. No: (034 433-0540
Province of negros Occiental
Provincial Administration Center Fax No: 707-2648
Bacolod City, Negros Occidental Email :
Project Classification: Date of Estimated Start/Execution of the project:
Estimated No. of
Road Concreting Workers to be Month Day Year
deployed in the
Total Project Cost: project: Duration of the project (Pls. state the
number of calendar days
Php 4,995,000.00 10
65 C. D.
(Workforce of the
project to include
workers of the
sub-contractor/s)
Brief Description of Activities/Work Flow (You may attach additional sheet, if necessary)
1. Concreting Works
Revised Form: CSHP-DO 13-98
Date of Revision: June1, 2011 Page
2of 3
APPLICATION FORM for
Department of labor and Employment APPROVAL OF
REGIONAL OFFICE NO. 6 CONSTRUCTION SAFETY AND
HEALTH PROGRAM
OSH Personnel assigned to the project
Name of Appointed Safety Officer/s: Name of Appointed First-
Aider/s:
Jean Paul Alexander B. Ortega
Arlene T. Lasquite
Date of his/her BOSH training: April 13-21,2006
Date of First –Aid Training:
(Pls. attach photo copy of Certificate of Completion on the Basic OSH Course June 10-13,2019
for Construction Site Safety Officers issued by DOLE-BWC accredited Safety
Training Organizations or recognized institutions)
Validity of ID: June 13,2021
(Pls. attach photo copy of
Certificate of First-Aid Training
and Valid First Aider ID from
PNRC
Other OH personnel (if more than 50 workers will be deployed in the project)
Name Date of BOSH
Training
N/A
OH Nurse
OH Physician
N/A
N/A
Dentist
(If Heavy Equipment will be used in the Project)
List of Heavy Equipment to be Used in the Project Name of Heavy Equipment
(Please attach additional sheet, if necessary) Operator/s (To attach photo copy
Backhoe,Payloader , Dumptruck,Road Grader,Road of skills certification from TESDA)
Roller, Water truck, Transit Mixer N/A
Profile of the person who prepared the CSH Program for the above mentioned Project:
Name and Signature Educational Background:
Bachelor of Science in Industrial
Engineering
Work Experience in OSH:
JEAN PAUL ALEXANDER B. ORTEGA Practicing Safety and health Officer
___________________________
Signature over printed name Other Qualifications:
N/A
I HEREBY CERTIFY ON MY HONOR TO THE TRUTHFULNESS OF THE ABOVE MENTIONED
INFORMATION. THE COMPANY HEREBY COMMIT TO STRICTLY IMPLEMENT THE ATTACHED
CONSTRUCTION SAFETY and HEALTH PROGRAM DESIGNED FOR THE ABOVE MENTIONED
PROJECT.
Submitted By:
Signature Over Printed Name: Jean Paul Alexander Ortega
Position: Authorized Managing Officer
Date: ____________
Revised Form: CSHP-DO 13-98
Date of Revision: June1, 2011 Page 3
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