Republic of the Philippines

Department of Public Works and Highways

CENTRAL OFFICE
Registry of Contractors for Civil Works Projects
Contractor’s Confidential Application Statement for
Registration (CCASR)

(Please read the attached Instructions)

I, Edwina L. Maghuyop of legal age, with postal address at __Calunasan Norte,

Loboc, Bohol,_ after having been duly sworn in accordance with the law, hereby depose
and say:
1. That I am the Proprietor/Authorized Managing Officer of_JACES_Builders and Construction
Supply duly authorized to make this statement, as evidenced by the attached written
authority from the proprietor/governing board of the firm,
2. That I hereby present the following information for registration with the Department of Public
Works and Highways.

A. GENERAL INFORMATION

1. Name of Firm/Company : JACES BUILDERS AND CONSTRUCTION SUPPLY________________

a. Head Office Address : Purok Central Line Number: _National Road_ Street Name: Calunasan Norte
Municipality/City: _Loboc_ Province: __Bohol__ Region: _VII__
Postal Code: __6316___ Country: __Philippines_____________
b. Telephone Number : __ (038) 500-0015_________
c. Fax Number : ___N/A___________________
d. Email Address : ___jacesbuilders&gmail.com__
e. Company TIN : ___727-503-688-000________

2. Foreign Contractors Only

a. Nationality : ______________________________
b. Philippine Address : Number: _________ Street Name: ______________________________
Municipality/City: ______________Province: ____________ Region: ___
Postal Code: ________________
c. Telephone Number : _________________________
d. Fax Number : _________________________
e. Email Address : _________________________
f. Percentage of Filipino : __________________ (if applicable)
Ownership

3. Person Managing the Affairs of the Firm: Attach Annex “A”

a. Name : __EDWINA L. MAGHUYOP__________
b. Designation : _Proprietor/Authorize Managing Officer_
c. Tax ID No. : _109-830-319________________
d. Birthdate : _October 17,1969_________________

2x2 ID Picture

e. Picture

f. Signature :

Signature

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DPWH-INFR-05-1015 Page 1 of 15
4. Authorized Liaison Officers: Attach Annex “B”

a. Name : 1. SILVESTRE P. MAGHUYOP 2. ANGELO L. MAGHUYOP 3. CZARINA JOY L. MAGHUYOP

b. Designation : 1. Project Engineer________2. Project Manager__ 3._ Liaison Officer_______
c. Tax ID No. : 1. __915-946-008_________2. _________________ 3. __605-833-392________
d. Birthdate : 1. November 26, 1960 2. October 10, 1998____ 3. September 5, 2001_____

2x2 ID Picture 2x2 ID Picture 2x2 ID Picture

e. Picture:

f. Signature:

Signature Signature Signature

A. LEGAL ASPECTS

1. Ownership

NAME(S) of Tax ID Number

Birthdate
Owner/Stockholders (TIN) Signature
(for Corporation)
EDWINA L. MAGHUYOP 109-830-319 October 17, 1969

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DPWH-INFR-05-1015 Page 2 of 15
 2. City/Municipal Business Permit: Attach Annex “C”
Date issued: _ January 18, 2022______
Validity period: ___December 31, 2022___
Tax Identification Number: __727-503-688-000__

3. BIR Tax Clearance (per EO 398, series of 2005): Attach Annex “H”
Date issued: __August 26, 2022_________
Validity period: _August 25, 2023________
Tax Identification Number: _727-503-688-000__

4. PhilGEPS Registration
Date issued: ___June 21, 2022_________
Validity period: ___June 28, 2023_______
Certificate Number: _20181169707323331477__

B. TECHNICAL ASPECTS (Contractor’s Work Experience)

1. PCAB License Information

Contractor Particulars
(Please refer to your PCAB License)

Sole Proprietor Region VII (Central Visayas)

License Particulars

License First Issue Date (mm/dd/yy) _05_/_18_/_2021 License No. 49501

Validity Period of this License/Renewal (mm/dd/yy) From: _07 /_01 /_2022_ To: _06_/_30_/_2023_
Principal Classification: General Engineering Category D
Other Classifications
NONE

Registration Particulars

Registration Date (mm/dd/yy): _05_/_18_/_2021_ Number: 2021-0661

Validity Period of this Registration (mm/dd/yy): From: _05_/_18_/_2021_ To: _05_/_18_/_2024_
Kinds of Project Respective Size Ranges
Road, Highway, Pavement, Railways, Airport, Small B
Horizontal Structures and Bridges Small B
Irrigation and Flood Control Small B
Dam, Reservoir & Tunneling Small B
Water Supply Small B
Port, Harbor and Offshore Engineering Small B

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DPWH-INFR-05-1015 Page 3 of 15
2. List of all contracts completed by the contractor both in government and in the private sector: Attach Annex “I”

Contractor’s Contract Date Categories of Total As Built

Role & Dimensions
Contract Participation Work Code Cost
Contract Name Owner Start Actual Refer to
ID % Refer to Per Work
Completion Attachment A
Attachment A Category (PhP)
mm/dd/yy mm/dd/yy
Concreting of Barangay Road Bonbon Lower, Sole Contractor Aug. 23, 2021 Sept. 2, 2021 RCP 0.05 km 94,800.00
Loboc, Bohol 100%
Purchase & Installation Villaflor, Loboc, Sole Contractor Sept. 7, 2021 Sept. 30,2021 Streetlighting 10 units 269,500.00
Of Solar Street Lights Bohol 100%
Rehabilitation of Cambance, Sole Contractor Sept. 6, 2021 Sept. 21, 2021 BIR 1-storey 199,500.00
Multi-Purpose Building Loboc, Bohol 100%
Improvement/Widening LGU-Sikatuna, Sole Contractor Sept. 24, 2021 Dec. 22,.2021 RCP 0.120 km. 979,852.41
Of Municipal Road Bohol 100%
Installation of Solar Street Villaflor, Loboc, Sole Contractor Dec. 14, 2021 Jan. 5, 2022 Streelighting 15 units 299,200.00
Lights Bohol 100%
Road Concreting, LGU-Albur, Sole Contractor Jan. 5, 2022 Jan. 28, 2022 RCP 0.40 km. 199,972.50
Sinajon-san Vicente St. Bohol 100%
Road Concreting, LGU-Albur, Sole Contractor Jan. 5, 2022 Jan. 28, 2022 RCP 0.52 km. 269,899.50
San Quintin Street Bohol 100%
Rehabilitation/Repair Cambance, Sole Contractor March 6, 2022 March 16, 2022 BIR 1-storey 124,000.00
Of Covered Court Loboc, Bohol 100%
Improvement of Taytay Taytay Sole Contractor March 4,2022 March 16, 2022 WSL 2 1,750 lm. 574,000.00
Waterworks Line Loboc, Bohol 100%
Completion of Barangay Gotozon, Loboc Sole Contractor March 12, June 1, 2022 BIR 1-storey. 631,000.00
Evacuation center Bohol 100% 2022
Road Concreting, Gotozon, Loboc Sole Contractor May 18, 2022 July. 28, 2022 RCP 0.220 km. 1,399,230.00
Obdulia Digal Strret Bohol 100%
Improvement/Widening LGU-Sikatuna, Sole Contractor April 4, 2022 August 16, RCP 0.285 km. 2,369,401.58
Of Local Core Roads Bohol 100% 2022
Supply and Delivery of Buenavista, Sole Contractor March 23, July. 24, 2022 BIR 1-storey 1,995,000.00
Materials for the Repair Loboc, Bohol 100% 2022
Of Multi-Purpose Bldg.
Light Installation / Jimili-an, Sole Contractor July 21, 2022 August 28, Electrical MPB 160,000.00
Electrical Wiring/Time Slot Loboc, Bohol 100% 2022
Machine
Improvement/ Calunasan Sole Contractor MPB 1-storey 519,500.00
Rehabilitation of Brgy. Multi- Norte, Loboc, 100%
Purpose Bohol
Covered Court
Improvement/ Jimili-an, Sole Contractor Concrete 420 m2 719,500.00
Rehabilitation/ Loboc, Bohol 100% Pavement
Concreting of Pavement for
Barangay Covered Court
Concreting of Farm to Tocdog Dacu, Sole Contractor RCP 166 m2 499,660.90
Market Road Loay, Bohol 100%
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DPWH-INFR-05-1015 Page 4 of 11
3. List of all on-going contracts including those already awarded but not yet started, both in government and in the private sector:
Attach Annex “J” NOTE: Cost must be in Philippine Pesos computed on the date of the signing of the contract.

Contract Date Percent Categories

Estimated
of Work
Contract Name of Participation Dimen Total Cost per
Owner Start Complete Code
ID Contract % WA TE Refer to -sions Work
mm/dd/yy mm/dd/yy
Attachment A Category
Site Development LGU-Sikatuna, Sole Contractor Sep.21, 2022 Nov 20, 2022 25.0% 3.33% Embankment & 2,800 m2 1,455,172.75
For Motor pool Bohol 100% Covered Canal

Road Concreting Songculan, Sole Contractor RCP 440 m2 1,000,000.00

Dauis, Bohol 100%
Repair of Comfort Tourism Sole Contractor 564,997.00
Rooms @ Heritage Complex, 100%
Building Loboc, Bohol
Barangay Road Candasag, Sole Contractor RCP 480 m2 988,450.00
Concreting Loboc, Bohol 100%
Concreting of Cambance, Sole Contractor RCP 520 m2 998,500.00
Barangay Road Loboc, Bohol 100%
Improvement of Cambague,
Barangay Road Alburquerque,
Bohol
Concreting of Local Barangay
Roads Abucay Norte,
Badiang,
Bahaybahay,
Can-agong,
Sikatuna,
 Bohol
Concreting of Badiang,
Barangay Road Sikatuna,
Bohol

Key: WA = Work Accomplished TE = Time Elapsed

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Page 5 of 11
C. FINANCIAL ASPECTS (Amounts shall be in Philippine Pesos): Attach Annex “K”

Amount
Total Assets 4,584,224.00
Current Assets 2,242,667.00
Total Liabilities 4,048.00
Current Liabilities 4,048.00
Total Net Worth 4,580,176.00
Current Net Worth 2,238,619.00
Gross Annual Turnover 1,518,920.00
(construction)

Taxpayer Identification Number (TIN) ___727-503-688-000__

D. AFFIDAVIT

I hereby certify that all information provided herein, including the annexes and enclosures
thereto, is true and correct, and I hold myself liable, criminally or civilly, for any
misrepresentation or false statement made herein.

Page No. _______________ Until 31 December 20 _______

Book No. _______________ PTR No. : _______________
Series No. _______________ Issued at : _______________
Issued on : _______________
TIN : _______________

I hereby authorize the Department of Public Works and Highways to investigate and
verify the said information.

In witness thereof, I have hereunto affixed my signature this ______ day of

________________, 20____ at _____________________________________, Philippines.

__EDWINA L. MAGHUYOP___
(Affiant)

(Republic of the Philippines )

PROVINCE/CITY OF __________________)

SUBSCRIBED and SWORN TO before me this _______ day of ____________________, 20_____

at _____________________ affiant exhibited to me his/her Community Tax Certificate No.
___________ issued at ________________________ on ____________________.

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DPWH-INFR-05-1015 Page 8 of 15
 ________________________
Notary Public Doc. No.
_____________ CONTRACTOR’S
CONFIDENTIAL APPLICATION STATEMENT FOR REGISTRATION (CCASR)

INSTRUCTIONS FOR CONTRACTOR’S APPLICATION

1. The Contractor-Applicant shall accomplish/answer all items in the Application Statement using
the English language. Answers must be given to all questions in the aforesaid statement. All
blanks shall be properly filled up. If necessary, additional sheets may be added to the form or,
if the form has limited space, it can be reproduced and enlarged to suit the Contractor
Applicant’s needs. Documents submitted on forms or in any format other than that prescribed
in the aforesaid Statement shall be considered non-complying and will be rejected outright.
Forms that may require attachments shall be clearly marked, i.e., Attachments to Form No.1;
Attachments to Form No. 2, etc.

2. The information/data submitted by the Contractor-Applicant are to be used by the DPWH in

determining, according to its judgment, the eligibility and qualification of the Contractor. In
view thereof, Contractor-Applicants are encouraged to communicate with the DPWH for any
clarification or interpretation of the documents. Requests for reconsideration will not be
entertained on any erroneous interpretations or conclusions made by the Contractor-Applicant.
A Contractor-Applicant submitting its qualifications as a prospective Contractor for review and
consideration waives any claim against any decision thereon. The signing by the Contractor or
his duly authorized representative of the Contractor-Applicant’s Application Statement for
Registration acknowledges the truth and correctness of all statements made therein;
otherwise, the Contractor shall be liable for perjury as provided in the Revised Penal Code.

3. Aside from the main Contractor’s Confidential Application Statement for Registration, the
following documents shall be annexed to and form part of the Statement:

Annex “A” Appointment or authority of the Authorized Manager of the Organization with
specimen signature duly notarized.
Annex “B” Appointment or authority of the officially designated Liaison Officer with specimen
signature duly notarized and copies of two (2) valid Government ID’s showing
his/her proper identification.
Annex “C” Certified True Copy of Contractor’s PCAB License for the current year
Annex “D” Certified True Copy of DTI (sole proprietorship), CDA (cooperatives) or SEC
(corporation)
Annex “E” Certified True Copy of Certificate of PhilGEPS Registration (Platinum Membership)
Annex “F” Certified True Copy of Articles of Incorporation (if applicable)
Annex “G” Certified True Copy of valid and current Mayor’s Business Permit
Annex “H” Certified True Copy of BIR Tax Clearance, per E.O. 398, series 2005
Annex “I” Certified True Copy of Contract Agreement and of Certificate of
Completion/Acceptance from the Implementing Office/Owner, with scope of work,
and Contract cost for completed contracts
Annex “J” Certified true copy of Contract Agreement from the Implementing Office/Owner,
with scope of work, Contract costs and statement from the Implementing Office
as to %WA and %TE for all ongoing contracts, and those already awarded but
not yet started, including certified true copy of NTP.

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DPWH-INFR-05-1015 Page 9 of 15
 Annex “K” Audited Financial Statement as reflected in Contractor’s Income Tax Return stamped
received by the Bureau of Internal Revenue
Annex “L” Letter authorizing verification of the integrity of the Registration documents
4. The Contractor’s Confidential Application Statement for Registration, including Annexes, shall
be submitted in one (1) envelope. The envelope should be captioned “Application for
Registration” and submitted preferably to the DPWH Central Office: Procurement Service. All
documents submitted shall be treated as confidential and will not be returned.

5. The DPWH will inform all applicants of the result of their application. It reserves the right to
accept or reject any application without any liability to the affected applicants or any
obligation to inform the applicants of the grounds for the action taken thereon.

Attachment A - TABLE OF MAJOR CATEGORIES OF WORK

Major Work Category Description

Work Work Category
Category Measure Code
Code

BCB Bridges: Construction - Bailey lm.

BCSDP Bridges: Construction - Steel (Superstructure) - with Driven Piles lm.

BCSCP Bridges: Construction - Steel (Superstructure) - with Cast-in-Place Piles lm.

BCCDP Bridges: Construction - Concrete (Superstructure) - with Driven Piles lm.

BCCCP Bridges: Construction - Concrete (Superstructure) - with Cast-in-Place lm.

Piles
BRHSDP Bridges: Rehabilitation - Steel (Superstructure) - with Driven Piles lm.

BRHSCP Bridges: Rehabilitation - Steel (Superstructure) - with Cast-in-Place Piles lm.

BRHCDP Bridges: Rehabilitation - Concrete (Superstructure) - with Driven Piles lm.

BRHCCP Bridges: Rehabilitation - Concrete (Superstructure) - with Cast-in-Place lm.

Piles
BRTSDP Bridges: Retrofitting - Steel (Superstructure) - with Driven Piles lm.

BRTSCP Bridges: Retrofitting - Steel (Superstructure) - with Cast-in-Place Piles lm.

BRTCDP Bridges: Retrofitting - Concrete (Superstructure) - with Driven Piles lm.

BRTCCP Bridges: Retrofitting - Concrete (Superstructure) - with Cast-in-Place Piles lm.

BCCWOP Bridges: Construction - Concrete (Superstructure) - without Piles lm.

BCSWOP Bridges: Construction - Steel (Superstructure) - without Piles lm.

BRHCWOP Bridges: Rehabilitation - Concrete (Superstructure) - without Piles lm.

BRHSWOP Bridges: Rehabilitation - Steel (Superstructure) - without Piles lm.

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DPWH-INFR-05-1015 Page 10 of 15
 BRTCWOP Bridges: Retrofitting - Concrete (Superstructure) - without Piles lm.

BRTSWOP Bridges: Retrofitting - Steel (Superstructure) - without Piles lm.

RCA Roads: Construction - Asphalt km.

RCG Roads: Construction - Gravel km.
RCP Roads: Construction - PCCP km.

RRA Roads: Rehabilitation - Asphalt km.

RRP Roads: Rehabilitation - PCCP km.
RCTP Roads: Construction - Tunnel - PCCP
RCSPNS Roads: Construction - Slope Protection using non - structural measures km.
(e.g. vetiver, coconet, other vegetation)

RCSPS Roads: Construction - Slope Protection using Structural Measures (e.g. km.
Revetment, Retaining structures, Wirenet)

RM Roads: Maintenance km.

BM Bridges: Maintenance km.
TEMS Traffic Engineering and Management System (including Road Safety lm.
Devices)
BICWPLCDP Buildings: Construction - with Piles - Low Rise - Concrete (Frame) - Driven storeys
Piles (1 to 5 Storeys)

BICWPLCCP Buildings: Construction - with Piles - Low Rise - Concrete (Frame) - Castin- storeys
Place Piles (1 to 5 Storeys)

BICWOPLC Buildings: Construction - without Piles - Low Rise - Concrete (Frame) (1 to storeys
5 Storeys)
BICWPHCDP Buildings: Construction - with Piles - High Rise - Concrete (Frame) - Driven storeys
Piles (6 & above Storeys)

BICWPHCCP Buildings: Construction - with Piles - High Rise - Concrete (Frame) - Castin- storeys
Place Piles (6 & above Storeys)

BICWOPHC Buildings: Construction - without Piles - High Rise - Concrete (Frame) (6 & storeys
above Storeys)
BICWPLSDP Buildings: Construction - with Piles - Low Rise - Steel (Frame) - Driven storeys
Piles (1 to 5 Storeys)
BICWPLSCP Buildings: Construction - with Piles - Low Rise - Steel (Frame) - Cast- storeys
inPlace Piles (1 to 6 Storeys)

BICWOPLS Buildings: Construction - without Piles - Low Rise - Steel (Frame) (1 to 5 storeys
Storeys)
BICWPHSDP Buildings: Construction - with Piles - High Rise - Steel (Frame) - Driven storeys
Piles (6 and above Storeys)

BICWPHSCP Buildings: Construction - with Piles - High Rise - Steel (Frame) - Cast- storeys
inPlace Piles (6 and above Storeys)

BICWOPHS Buildings: Construction - without Piles - High Rise - Steel (Frame) (6 and storeys
above Storeys)
BIR Buildings: Repair storeys

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DPWH-INFR-05-1015 Page 11 of 15
 BIRTL Buildings: Retrofitting - Low Rise storeys

BIRTH Buildings: Retrofitting - High Rise storeys

FCG Flood Control: Construction - Gates unit

FCDG Flood Control: Construction - Dam with Gates unit
FCRB Flood Control: Construction - Retarding Basin cu.m.
FCSP Flood Control: Construction - Shore Protection (Seawall, Breakwater) lm.

FCSPNS Flood Control: Construction - Slope Protection using non - structural lm.
measures (e.g. vetiver, coconet, other vegetation)

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DPWH-INFR-05-1015 Page 12 of 15
 FCSPS Flood Control: Construction - Slope Protection using Structural Measures lm.
(e.g. Revetment, Retaining structures, Wirenet)

FCD Flood Control: Construction - Dams cu.m.

FMDRE Flood Control: Maintenance - Dredging, Desilting, River cu.m.
Rechanneling/Excavation Works
FCCE Flood Control: Construction - Channel Excavation cu.m.

HD Harbors: Dredging cu.m.

FCN Flood Control: Construction - Drainage (Closed and open) Conduits lm.

FCP Flood Control: Construction - Pumping Station unit

FCDKL Flood Control: Construction - Dikes/Levees lm.
FCBPS Flood Control: Construction - Bank Protection Structure

WSL1 Water Supply (Level 1): Construction (Shallow Wells/Rainwater Collectors) lm.

WSL2&3 Water Supply (Level 2 & 3): Construction (Piped Water with
Communal/Private Water Point)

PCCWDP Ports/Harbors: Construction - Causeway/Wharf - with Driven Piles lm.

PCCWCP Ports/Harbors: Construction - Causeway/Wharf - with Cast-in-Place Piles lm.

PMCWDP Ports/Harbors: Maintenance - Causeway/Wharf - with Driven Piles lm.

PMCWCP Ports/Harbors: Maintenance - Causeway/Wharf - with Cast-in-Place Piles lm.

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DPWH-INFR-05-1015 Page 13
 of 11

ANNEX “L”

ANNEX “L”

LETTER AUTHORIZING VERIFICATION OF THE INTEGRITY OF

REGISTRATION DOCUMENTS

Name of the Head of the Procuring Entity

Position of the Head of the Procuring Entity
Name of the Procuring Entity
Address

Dear __________________:

________________________________________________________________________
(Name of Firm)

I hereby request that our application for inclusion of the above-mentioned firm in the DPWH
Registry of Contractors for Civil Works be approved.

I am fully aware that:

1. all documents submitted in support of this application are subject to verification by the
DPWH, and

2. any discovered misrepresentation of information and/or manifestations of fraud on the

application documents submitted by our firm applicant or its Authorized
Representative/Agent/Liaison Officer shall be subjected to investigation which may result in
the disapproval/denial/suspension/revocation of this application and blacklisting of our firm
and myself as its Authorized Managing Officer; and

Name and Signature

Authorized Managing Officer

Republic of the Philippines)

_____________________) S.S.

SUBSCRIBED AND SWORN TO before me this ________ day of ___________________, 20____ at

______________________; affiant exhibited to me his Community Tax Certificate No.
_______________ issued at __________________ on _________________ 20 ___.

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DPWH-INFR-05-1015 Page 14
 Doc. No. ___________;
Page No. ___________;
Book No. ___________;

Name and Signature

NOTARY PUBLIC
(Until December 31, 20__)

of 11

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DPWH-INFR-05-1015 Page 15