NO FEES REQUIRED FOR THE FILING , EVALAUTION AND APPROVAL OF CSHP

Revised Form.: CSHP-DO13-98:

Date of Revision : June1, 2011 Page 1of 3

REVISED APPLICATION FORM for

Department of Labor and Employment EVALUATION/ APPROVAL OF
REGIONAL OFFICE NO. _NCR_ CONSTRUCTION SAFETY & HEALTH
PROGRAM (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:
Main /General Contractor Gallardo St. Poblacion, Balanga City, Bataan
Tel. No:
SUPREME BUILDERS CONSTRUCTION AND Fax No.
TRADING
Name of Project Manager/Contact Person: Email:
HUBERT BALUYOT PIZARRO
Main Contractor PCAB License No. 36299 Main Contractor Total employment _______
Date of Validity: July 31, 2019 to June 30, ___ Male _____ Female _____
2020
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) June 19, 2017 DOLE-Balanga City

Sub-contractors’ Profile/License
Name of Sub-contractors (If , any) Scope of Work and No. of PCAB Validity Date of DOLE
Project Cost Workers License Date Registration
1.

2.

3.

4.

5.

(Use separate sheet , if necessary)

B. Project Profile/Description
 REVISED APPLICATION FORM for
Department of Labor and Employment EVALUATION/ APPROVAL OF
REGIONAL OFFICE NO. _NCR_ CONSTRUCTION SAFETY & HEALTH
PROGRAM (CSHP)
Name of the Project: (Please attach copy of Invitation to Bid/other documents indicating name and details of the project)

Contract ID No. 18CA0062-Local Infrastructure Program-Construction of Multi-Purpose

Building,Barangay Mabatang,
Complete Project Address/Location

Abucay, Bataan

Name of Project Owner

Tel. No: ____________
DPWH – BATAAN 1ST DEO
Fax No: ____________

Email : _____________

Project Classification: Date of Estimated Start/Execution of the

Estimated No. of Workers to be project:
deployed in the project:
Multi-Purpose Building Month Day Year
15
(Workforce of the project to
Project Cost: include workers of the sub- Duration of the project (Pls. state
contractor/s) the number of calendar days
4,876,238.00
90 CD

Brief Description of Activities/Work Flow (You may attach additional sheet, if necessary)

Revised Form.: CSHP-DO 13-98 Date of Revision: June1, 2011 Page 2 of 3

 Department of labor and Employment APPLICATION FORM for APPROVAL OF
REGIONAL OFFICE NO. _NCR_

CONSTRUCTION SAFETY AND HEALTH PROGRAM

OSH Personnel assigned to the project

Name of Appointed Safety Officer/s: Name of Appointed First-Aider/s:

HUBERT B. PIZARRO EDGARDO I. DE LEON, JR.
Date of his/her BOSH training: OCT. 11-15, 2011 Date of First –Aid Training: FEBRUARY 26, 2014
(Pls. attach photo copy of Certificate of Completion on Validity of ID: PRC ID
the Basic OSH Course for Construction Site Safety Officers (Pls. attach photo copy of Certificate of First-Aid
issued by DOLE-BWC accredited Safety Training Training and Valid First Aider ID from PNRC
Organizations or recognized institutions)
Other OH personnel (if more than 50 workers will be deployed in the project)
Name Date of BOSH Training
OH Nurse
OH Physician
Dentist
(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 (To attach
(Please attach additional sheet, if necessary) photo copy of skills certification from TESDA)

Profile of the person who prepared the CSH Program for the abovementioned Project:
Name and Signature Educational Background:
BS NURSING
Work Experience in OSH:

Other Qualifications:
HUBERT B. PIZARRO
COSH TRAINING
Signature over printed name
8 HOURS FIRE SAFETY TRAINING (March 22, 2019)
DOLE/OSHC 40 HOUR TRAINING LOSS CONTROL MANAGEMENT
– March 18-21, 2019-

I HEREBY CERTIFY ON MY HONOR TO THE TRUTHFULLNESS OF THE ABOVEMENTIONED INFORMATION. THE

COMPANY HEREBY COMMIT TO STRICTLY IMPLEMENT THE ATTACHED CONSTRUCTION SAFETY and HEALTH
PROGRAM DESIGNED FOR THE ABOVEMENTIONED PROJECT.

Submitted By:

Signature Over Printed Name: HUBERT BALUYOT PIZARRO

Position: MANAGER/OWNER

Date:

Revised Form.: CSHP-DO 13-98

Date of Revision: June1, 2011 Page 3 of 3

Republic of the Philippines

Department of Public Works and Highways
Bataan First District Engineering Office
OFFICE OF THE DISTRICT ENGINEER
Roman Expressway, Mulawin, Orani, Bataan

To : MA. ZENAIDA A. ANGARA-CAMPITA

Regional Office
Department of Labor and Employment
Subject : APPROVAL OF CONSTRUCTION AND HEALTH PROGRAM
Approval Number :
Project Title : Contract ID No. 18CA0062-Local Infrastructure Program-Construction
of Multi-Purpose Building,Barangay Mabatang, Abucay, Bataan
Project Owner : SUPREME BUILDERS CONSTRUCTION AND TRADING
Main/General Contractor’s PCAB License No.: 36299
Date Validity : July 1, 2017 to June 30, 2018
Appointed Safety Officer : HUBERT B. PIZARRO
Appointed First Aider/s : EDGARDO I. DE LEON, JR.
OH Nurse : EDGARDO I. DE LEON, JR.
OH Physician :
Total Number of Workers : 15
Duration of Projects :
Date of Estimated Start/Execution of the Project:
No. of Sub-contractors:
Name of Sub-Contractor PCAB License Date of Validity

(Use Separate Sheet, if necessary for the complete list of subcontractors)

This refers to above captioned Construction Safety and Health Program (CSHP) which was submitted to this Office on
_____________________ in compliance with D.O. 56 Series of 2005.
Based on the evaluation of the requirements submitted by the main/general contractor, said Program satisfactorily
complied with the minimum requirements of D.O. No. 56, series of 2005.
In view of the foregoing, and subject, however, to the concurrence of Department of Labor and Employment (DOLE) in
accordance with D.O. No. 129, Series of 2014, the instant CSHP is hereby APPROVED for implementation in the
abovementioned project. The main/general contractor shall be responsible in ensuring its sub-contractors’ compliance
with the provisions of DO 56, specifically on the implementation of suitable CSH Program designed for the specific work
to be done by the sub contractor/s.

The approved CSHP shall not be limited to its existing provisions but may include other systems and procedures
applicable to the project. The CSHP may be reviewed by the main contractor from time to modify or include appropriate
systems and procedures which must be in accordance with the prescribed standards, rules and regulations.

Let a copy of this letter be furnished the tendering agency and the appropriate LGU for their respective information
and/action as they deem fit.

Reviewed by: Approved by:

DELANO R. BALUYOT ERLINDO R. FLORES, JR.

Chief, Construction Section OIC-District Engineer

Concurred by:

________________________
DOLE