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Revised Form.: CSHP-DO13-98:Date of Revision : June1, !11 Pa"e 1of 3

De#artment of $a%or and &m#'o(ment

REGIONAL OFFICE NO. ___

REVISED APPLICATION FORM forEVALUATION/ APPROVAL OFCONSTRUCTION SAFETY & HEALTHPROGRAM (CSHP)

Leg! "#$#% Se)tion * of De#artment Order +o. 13 s 1998 uide'ines overnin" O))u#ationa' Safet( and Hea't /n Constru)tion /ndustr(0

I#'r'$o#: is form sa'' %e du'( a))om#'ised and su%mitted %( te MAIN/GENERALCONTRACTOR in a##'(in" for an a##rova' of a Constru)tion Safet( and Hea't Pro"ram intended fora s#e)ifi) )onstru)tion #ro2e)t.

+ote: A CHEC*LIST OF RE+UIREMENTSsa'' %e used in re)eivin" te a##'i)ation.

On'( an a##'i)ation form it a )om#'ete re4uirements and atta)ments i'' %e #ro)essed.5##'i)ation found it in)om#'ete re4uirements i'' %e "iven 1* )a'endar da(s to )om#'(. Fai'ure to)om#'( itin te #res)ri%ed #eriod, te a##'i)ation i'' %e deemed disa##roved.

A. Co,- Prof$!e/L$e#e/Reg$#'r'$o of M$/Geer! Co'r'orCom#'ete +ame of te Com#an(67ain 6enera' Contra)tor

Com#'ete 5ddress:

e'. +o:

Fa +o.

+ame of Pro2e)t 7ana"er6Conta)t Person: &mai':

7ain Contra)tor PC5 $i)ense+o.

Date of ;a'idit(:

7ain Contra)tor ota' em#'o(ment 7a'e Fema'e

DO$& Re"istration of 7ain Contra)tor P's. atta) #oto )o#( of Re"istration forms re)eived and a##roved %(te )on)erned DO$& Re"iona' Offi)e0

Date Re"istered65##roved DO$&-RO

a. #er DO 0123 re4uires (ear'( renea'0

%. #er R!e 2324 OSHS one time re"istration0

S51o'r'or#6 Prof$!e/L$e#e

+ame of Su%-)ontra)tors /f , an(0 S)o#e of

7/25/2019 Revised Form CSH program

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De#artment of $a%or and &m#'o(ment

REGIONAL OFFICE NO. ___

REVISED APPLICATION FORM forEVALUATION/ APPROVAL OFCONSTRUCTION SAFETY & HEALTHPROGRAM (CSHP)

". Pro8e' Prof$!e/De#r$-'$o

+ame of te Pro2e)t: P'ease atta) )o#( of /nvitation to id6oter do)uments indi)atin" name and detai's of te#ro2e)t0

Com#'ete Pro2e)t 5ddress6$o)ation

+ame of Pro2e)t Oner

e'. +o:

Fa +o:

&mai' :

Pro2e)t C'assifi)ation:

ota' Pro2e)t Cost:

&stimated +o. of ear

Duration of te #ro2e)t P's.state te num%er of )a'endar da(s

rief Des)ri#tion of 5)tivities6

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De#artment of 'a%or and &m#'o(ment

REGIONAL OFFICE NO. ________APPLICATION FORM for APPROVAL OF

CONSTRUCTION SAFETY AND HEALTH PROGRAM

OSH Per#oe! ##$ge9 'o '7e -ro8e'

+ame of 5##ointed Safet( Offi)er6s:

Date of is6er OSH trainin":

P's. atta) #oto )o#( of Certifi)ate of Com#'etion on teasi) OSH Course for Constru)tion Site Safet( Offi)ers issued%( DO$&-$-,e' ;$!! 5e #e9 $ '7e Pro8e')$ist of Heav( &4ui#ment to %e Ased in te Pro2e)tP'ease atta) additiona' seet, if ne)essar(0

+ame of Heav( &4ui#ment O#erator6s o atta) #oto)o#( of s=i''s )ertifi)ation from &SD50

Prof$!e of '7e -er#o ;7o -re-re9 '7e CSH Progr, for '7e 5o=e,e'$oe9 Pro8e'%+ame and Si"nature

Si"nature over #rinted name

&du)ationa' a)="round: