Application No.

: _____________

Regional Office: 12

Application for
CONSTRUCTION SAFETY AND HEALTH PROGRAM (CSHP)
(Intended ONLY for Residential Project/s (2 storey and below) or minor repair with less than 10 workers)

Project Name: ___PROPOSED CONSTRUCTION OF GATE & PERIMETER FENCE____________________________

Project Complete Address/Location: __NURSERY ROAD, BRGY. KATANGAWAN, GEN. SANTOS CITY___________

Project Duration: ___ 20 DAYS_ Project Start: _AUG 19, 2019_ Completion Date: _SEP 11, 2019__________
(No. of Calendar days) (Date of estimated start) (Date of project completion)

Estimated Project Cost: ___P __226, 415.21___________Number of workers: __5 WORKERS_______________

Name of Contractor (if any) ___N / A______________________________________________________________

Contractor’s Address: ________N / A_________________________ Email Address: _______________________

PCAB License No.: ____________N / A_________________ Date of validity: _____________________________

Name of Project Owner: _KERWIN WILLIAM TAN____________________________________________________

Tel/Fax No.: _____________________________ Email Address: _______________________________________

Submitted by: _ENGR. MICHAEL JAN M. DE CELIS____ _________CIVIL ENGINEER________

Signature over printed name Position

COMMITMENT TO COMPLY ON OSH

I/We ____ENGR. MICHAEL JAN M. DE CELIS__ and _________KERWIN WILLIAM TAN________________

Name of Contractor’s Authorized Official and/or Project Owner)
do hereby commit and bind ourselves 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. We hereby commit to implement a suitable Construction Safety and
health Program designed for the above-mentioned project. We also acknowledge 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.

______KERWIN WILLIAM TAN__________ ___ENGR. MICHAEL JAN M. DE CELIS____

Name of Project Owner Name of Contractor
Signature over Printed Name Signature over Printed Name