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 Two Storey 4-units Apartment__________________________________

Project Complete Address/Location: __Lot 9-H-6 Mangga Village, San Agustin, City of San Fernando, Pamp.__
_________________________________________________________________________________________
Project Duration: _180 days_____ Project Start: _February_______ Completion Date: _August___________
(No. of Calendar days) (Date of estimated start) (Date of project completion)
Estimated Project Cost: _PHP 2,341,377.39______ Number of Workers: ___12__________________
Name of Contractor (if any):__Harold E. Manabat_________________________________________________
Contractor’s Address: ___Betis, Guagua, Pampanga ______________________________________________
____________________________________________________________ Fax No.:_______________________
PCAB License No.______________ Date of Validity: ____________ Email address: ar.harold.manabat@gmail.com

Name of Project Owner: ___Marilou Maruyama_______________ Fax No.:_____________________

Project Owner Address: _402 Eloisa St., Mangga Village, San Agustin, City of San Fernando, Pampanga_______
______________________________________________________ Email address: ____________________

Accomplished by: ___ Marilou Maruyama_______

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

I/We __ __Harold E. Manabat_ ____ and ____ __Marilou Maruyama__________

(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.
___________Marilou Maruyama___________ __ _Harold E. Manabat
_________
PROJECT OWNER CONTRACTOR
Signature Over Printed Name Signature Over Printed Name

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