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PCAB Form No.

201

APPLICATION FOR RENEWAL OF CONTRACTOR'S LICENSE with the PHILIPPINE CONTRACTOR'S ACCREDITATION BOARD
The following pertinent documents and information are to be submitted in support of the license application of said firm:

Checklist for Renewal Application

A. Legal [ ] 1. General Information (PCAB Form Nos. 201a and 202); [ ] 1.1 Certified true copy of Amendments (if any) to Articles of Incorporation and/or by-Laws in case of Corporate or Partnership applicant;

B. Financial [ ] 2. Annual Income Tax Return filed with the BIR for the taxable year immediately preceding the filing of renewal application; [ ] 3. Financial Statements (duly audited and signed on every page by a PRC-BOA accredited external auditor) as of the end of the taxable year immediately preceding the filing of application duly filed with the BIR and a diskette / CD (compact disc) containing the firms Audited balance Sheet & Income Statement in the prescribed template (PCAB Financial Statement Forms A & B downloadable from the DTI website at www.business.gov.ph together with the pertinent application forms).
3.1 Documents in support of new acquisitions of: 3.1.1If increase is due to additional capital infusion / assets [ ] 3.1.1.1 Cash - Original copy of Bank Certification/Bank statement of account certified by Bank Manager

3.2 If increase is due to appraisal of properties [ ] 3.2.1 Independent Appraisers Report

of cash deposits as of the Balance Sheet date; Authorization to Depository Bank (PCAB Form No. 203a); (NOTE: Amounts in excess of of 1% of the minimum networth required for the contractors existing category or P 50,000.00 reflected as Cash or Cash on Hand will be deducted from the Networth if unsupported) [ ] 3.1.1.2 Land and Building - List of Land and Building/s owned by the company and registered in its name (PCAB Form No. 204a); Certified true copy of TCT including back page for newly acquired land and/or condominium which were not previously reported/submitted to PCAB. Certified true copy of Deed of Sale or Tax Declaration of newly acquired / newly constructed building, which were not previously reported / submitted to PCAB. [ ] 3.1.1.3 Transportation & Construction Equipment - List of Construction and/or Transportation/Delivery Vehicles/Equipment/Machineries/Plants owned by the company and registered in its name, (PCAB Form No. 204b); Certified true copy by the LTO of the LTO Certificate of Registration and current Official Receipt of Registration of newly acquired registrable Construction and/or Transportation/ Delivery Vehicles/Equipment Certified true copy of Deed of Sale or sales invoices/official receipts for newly acquired non-registrable construction equipment/machineries/plants, [ ] 3.1.1.4 Other Assets (i.e. Investment in Banks and /or Shares of Stocks and other accounts) Certified true copies of certificates of Stock, time deposits, & other pertinent proofs of ownership of other assets

[ ] 4. Authorization to BIR & other agencies (PCAB Form No. 203); C. Experience of Firm [ ] 5. Statement of Annual Value of Work Accomplished (PCAB Form 205) D. Technical [ ] 6. List of STEs (PCAB Form No. 204) supported by applicable documents (listed below) for each STE; For newly nominated STE/s: [ ] 6.1 STE Affidavit/s (PCAB form 206) with a passport size picture/s of the new STE/s; [ ] 6.1.1 Valid PRC ID of STE as licensed professional or original certification of Good Standing for those awaiting issuance of new or renewed PRC ID. [ ] 6.1.2 NBI clearance/s of new STE/s; [ ] 6.2 STE Affidavit/s of Construction Experience (PCAB Form 207); [ ] 6.3 Personal Appearance Form duly accomplished and signed by the STE/s appearing before the designated officer of the PCAB or the nearest DTI regional/provincial office (PCAB Form No. 208) For previously nominated STE/s: [ ] 6.4 STE Affidavit/s (PCAB form 206); [ ] 6.4.1 For STE/s below 60 years old: Copy of the pertinent page of CCL (formerly SSS Form R3) submitted to SSS for the quarter immediately preceding the filing of application; [ ] 6.4.2 For STEs 60 years old and above: Copy of Certificate of Income Tax withheld on compensation (BIR Form 2316, formerly BIR W-2) for the taxable year , immediately preceding the filing of application issued by the firm to the employee and duly stamped received by BIR/ or accredited bank. Others: PCAB Response Form (self-addressed and with sufficient stamps affixed) NOTE : Original signature of Proprietor/AMO on each & every page of application forms including supporting documents (except item 6.3). : Photocopies of documents, in lieu, of certified copies are accepted provided the original copies are presented for authentications.
DO NOT FILL (For PCAB use only) Total No. of Pages Submitted: _______ Checklisted by: _____________________________ [ ] Self-stamped envelopes * (no. ______ ) Name over Signature/Date Remarks: _________________________________ ________________________________________ __________________________________ ________________________________________ * One for each depository bank; one each for BIR, LTO, & LRA; and one for each vendor of non-registrable construction equipment reported
Revised 03/06/07

PCAB Form No. 201a

In behalf of

JOHN DEE B. BUSTAMANTE CONSTRUCTION__________________,


(Name of Firm)

holder of Contractor's License No. 30458, originally issued on AUGUST 30, 2002, I hereby request for Renewal of its Contractor's License for Contracting Fiscal Year 01 July 2011 to 30 June 2012.
I hereby certify to the completeness of the information/documents contained in this application appertaining to the category/classification the company is applying for and that they are true and correct. I am fully aware that: 1. all documents submitted in support of this application are subject to verification before PCAB action; 2. any discovered misrepresentation of information and/or manifestations of fraud on the application documents submitted by my firm applicant or its Authorized Representative/Agent/Liaison Officer shall be subjected to investigation which may result to the disapproval of my application, denial/suspension/revocation of license and blacklisting of my firm and myself as its Authorized Managing Officer; and 3. unconfirmed information/documents submitted to support my firm's qualifications will be excluded for categorization/classification purposes. 4. the evaluation of my application's qualification shall be solely based on the documents submitted at the time the application was filed/accepted by PCAB.

_JOHN DEE B. BUSTAMANTE Authorized Managing Officer


(Signature over Printed Name)

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 _BALER, AURORA on _______________.

DOC. NO. PAGE NO. _________________________ BOOK NO._______________; SERIES OF_______________.

_______________; _______________; NOTARY PUBLIC (Until December 31, _______)

PCAB Form No. 202

GENERAL INFORMATION
A. CONTRACTORS IDENTIFICATION Name of Firm: JOHN DEE B. BUSTAMANTE CONSTRUCTION Office Address: BAYS INN, Sitio Labasin st. Brgy. Sabang, BALER, AURORA Tel./FaxNo: 09189266697 If Provincial based, contact address in Manila, if any: #51 ANAHAW ST. PROJ. 7, QUEZON CITY Website: Type of Organization (Please Check): [ ] Corporation [ ] Partnership SEC/BTRCP Registration No.: N/A Employers I.D. No.: 02-0933685-0 Original Contractor's License No.: 30458 License was last renewed during CFY 2010-2011 PRESENT CATEGORY: D Tel./Fax No: 372-25-06 E-mail Address: jbbcon_02@yahoo.com

[ / ] Sole Proprietorship

[ ] Joint Venture

Date of Registration: N/A

SEC/BTRCP Expiry Date: N/A

Tax Identification No.: 918-233-559 Date of Issue: AUGUST 30,2002

PRESENT CLASSIFICATION/S: Principal: GENERAL ENGINEERING Others: GENERAL BUILDING B. OWNERS/STOCKHOLDERS/OFFICERS* (For Corporation, Partnership and Joint Venture) Name Position Nationality Capital Subscription Paid-Up Capital

N/A

C. AFFILIATION WITH OTHER LICENSED CONTRACTORS Name of Affiliated Firm Nature of Affiliation

N/A

CERTIFIED CORRECT BY: JOHN DEE B. BUSTAMANTE Authorized Managing Officer (Signature over Printed Name)

Revised 03/31/04

PCAB Form No. 203

AUTHORIZATION
The Philippine Contractors Accreditation Board (PCAB) is hereby authorized to verify and secure information and/or copies of documents submitted by or in the name of the firm to any or all of the following agencies relative to its application filed with the PCAB: 1. 2. 3. 4. 5. Bureau of Internal Revenue Securities and Exchange Commission Land Registration Authority Land Transportation Office Social Security System

Name of Applicant Firm

JOHN DEE B. BUSTAMANTE CONSTRUCTION

By: JOHN DEE B. BUSTAMANTE Signature over Printed Name of Proprietor or Authorized Managing Officer

Date: _________________________________

03/31/04

PCAB Form No. 203a

THE MANAGER

DEVELOPMENT BANK OF THE PHILIPPINES

Brgy. Suklayin, Baler, Aurora Subject: Account # 0520-290557-530 Maam: Please provide the Philippine Contractors Accreditation Board (PCAB), a government agency under the Department of Trade and Industry, any information they need regarding the subject account with your bank. I am applying for a contractor's license from PCAB and part of their evaluation process is the verification of bank deposits and other assets of an applicant. This will serve as your authorization to release any information that may be requested by PCAB regarding the above subject account. Thank you. Very truly yours,

JOHN DEE B. BUSTAMANTE Signature over Printed Name JOHN DEE B. BUSTAMANTE CONSTRUCTION Company Name ___________________________________ Date

Note: To be submitted in two (2) copies.

Revised 03/31/04

PCAB Form No. 204

LIST OF NOMINATED SUSTAINING TECHNICAL EMPLOYEES OF THE COMPANY


PRC REGISTRATION Number RODEL B. LACHICA 35428 Profession CIVIL 06/26/84 ENGINEER Date Date Employed 07/2OO2 Position in the Firm PROJECT ENGINEER

NAME

May be reproduced if necessary

Revised 03/31/04

JOHN DEE B. BUSTAMANTE


Signature over Printed Name of AMO

JOHN DEE B. BUSTAMANTE CONSTRUCTION


Company Name

30458
PCAB License No. (If applicable)

________________________________________
Date Signed

CFY 2011-2012 Type of Application: (Pls. check) New Upgrading

x Renewal

Others, pls. Specify __________________________ __________________________ __________________________

PCAB FORM 205

STATEMENT OF ANNUAL VALUE OF WORK ACCOMPLISHED As of the year ending 2010


PROJECT PARTICULARS: 1 2 CONCRETING OF ROAD ALONG BALER PUBLIC MARKET DPWH AURORA BRGY. SUKLAYIN, BALER, AURORA GE-1 945,000.00 / 3 CONSTRUCTION OF MULTI PURPOSE PAVEMENT DPWH AURORA BRGY. OBLIGACION, BALER, AURORA GE-1 477,500.00 /

Title of project:

CONCRETING OF ROAD

Project owner: Location: Classification/Total Cost :

DPWH AURORA BRGY. BAGTU, MARIA AURORA, AURORA GE-1 / 950,000.00

CONTRACT PARTICULARS Date of contract:


MARCH 24, 2010 MARCH 24, 2010 JUNE 08, 2010 MAIN CONTRACTOR 937,594.20 JOHN DEE B. BUSTAMANTE CONSTRUCTION MARCH 22, 2010 MAY 08, 2010 MAIN CONTRACTOR 472,457.47 JOHN DEE B. BUSTAMANTE CONSTRUCTION

Contract completion JUNE 07, 2010 time : Scope of work: Amount of contract: Name of Main Contractor or Joint Venture Partner, if any:
MAIN CONTRACTOR 935,751.85 JOHN DEE B. BUSTAMANTE CONSTRUCTION

WORK ACCOMPLISHMENT

As of start of year: As of end of year :

______________ %_____ ______________ %100

______________ %_____ ______________ %100

_____________ %______ _____________ %100

TECHNICAL EMPLOYEE(S) Name and Profession: Position Title:


RODEL B. LACHICA CIVIL ENGINEER RODEL B. LACHICA CIVIL ENGINEER RODEL B. LACHICA CIVIL ENGINEER

PROJECT ENGINEER

PROJECT ENGINEER

PROJECT ENGINEER
Revised 03/31/04

*** NOTES: See instructions at the back before filling up this form. This may be reproduce if necessary. ***

JOHN DEE B. BUSTAMANTE Signature over Printed Name JOHN DEE B. BUSTAMANTE CONSTRUCTION Company Name 30458 PCAB License No.

INSTRUCTIONS ON FILLING-UP PCAB FORM-205


PROJECT TITLE refers to the name of the particular project as stated in the contract. PROJECT OWNER refers to either government infrastructure agencies (e.g. DPWH, LWUA, MWSS, NIA, DOTC, etc.) LOCATION refers to the site of the particular project. CLASSIFICATION refers to the coverage or type of the work as stipulated in the contract. Choose a code of the following: (e.g. GE-1, GE-3, GB-1, SP-5, etc.) GENERAL ENGINEERING GE-1 Road, Highway Pavement, Railway Airport hor. Structure & Bridges Piling Work GE-2 Irrigation or Flood Control Soil Stabilization/Slope GE-3 Dam, Reservoir or Tunneling GE-4 SP-SS GE-5 Port, Harbor and Recreation Work GENERAL BUILDING GB-1 Building and Industrial Plants Mechanical Work GB-2 Sewerage and Sewage System GB-3 Water Treatment Plant& System GB-4 Park, Playground and Recreation Work SPECIALTY SP-FP Foundation or Piling Work FP2 Protection/Reinforced Earth Water Supply Structural Steel Works SP-CC Concrete Pre-Casting, Pre-stressing, or Post-Tensioning SP-PS Plumbing and Sanitary Work SP-EE Electrical Work SP-ME SP-AC Air-Conditioning or Refrigeration SP-ES Elevator and Escalator SP-FW Fire Protection Work SP-WP Water Proofing Work SP-PN Painting Work SP-WD Well Drilling Work SP-PP Power Generating Plants/ Power Transmission & Distribution SP-CF SP-MS SP-SD SP-LS SP-NF SP-EM Communication Facilities Metal Roofing & Siding Installation Structural Demolition Landscaping Navigational Facilities Electro Mechanical Work

FP1

Facilities

TOTAL COST refers to the overall project cost inclusive of owner furnished materials but exclusive of design and engineering fees and may be in the nature of a budgetary estimate. DATE OF CONTRACT refers to the date the contract was signed. CONTRACT COMPLETION TIME refers to the date the project will be finished or completed. SCOPE OF WORK refers to the extent of involvement in the contract whether: (a) Main Contractor, (b) Sub-Contractor or (c) Joint Venture. AMOUNT OF CONTRACT refers to the contract sum of the applicant firm inclusive of any change/variation/order/addition or deduction. NAME OF MAIN CONTRACTOR or JOINT VENTURE PARTNER indicate the name of the Main Contractor or Joint Venture Partner if the project undertaken is a sub-contract. WORK ACCOMPLISHMENTS - AS OF START AND END OF YEAR refers to the stage of completion of the contract work as of the first day and the last day, respectively, of the calendar/fiscal year, based on the contract billings (indicate the value and percent accomplishments). TECHNICAL EMPLOYEE(S) IN-CHARGE OF PROJECT refers to the Engineer or Architect assigned to supervise the actual construction implementation (indicate the name, profession and position title of the STE).

PCAB Form No. 206 Passport size Picture of STE

Republic of the Philippines ) Province of AURORA ) Municipality of BALER ) S.S.

STE AFFIDAVIT
I,__________LACHICA born on
LAST NAME

RODEL

FIRST NAME

BAUTISTA

COMPLETE MIDDLE NAME

_, Filipino, of legal age,

0 3 1 1 1 9 6 1 single/married to ________NEOVE BIHASA LACHICA____and


M M / D D/ Y Y Y Y

residing at ___T. MOLINA ST. BALER, AURORA accordance with law depose and say:
(PROFESSION)

__________ having duly sworn in

1. That I am a duly licensed __CIVIL ENGINEER___ and holder of PRC registration no. _35428 valid up to _____________________ (copy of my PRC is attached at the back hereof); 2. That I hold a Bachelor's Degree in __BACHELOR OF SCIENCE IN CIVIL ENGINEER______ at _____________UNIVERSITY OF THE EAST ______ given on ___JUNE 26, 1984 ___; (NAME OF SCHOOL) 3. That my Tax Identification Number (TIN) and Social Security No. are 1 3 4 - 4 5 6 - 0 6 1 and 0 3 - 5 8 5 5 6 3 5 - 8 respectively;
4. That I am not presently employed in any government office or government owned/controlled corporation, nor a full time instructor, nor working abroad;
(NAME OF FIRM)

5. That I am employed by ______JOHN DEE B. BUSTAMANTE CONSTRUCTION___________ on regular and full-time basis with the position of ___PROJECT ENGINEER____and presently being nominated as Sustaining Technical Employee for CFY __2011-2012; 6. That I am not a holder of a contractor's license; 7. That I am not involved in any construction malperformance suggestive of negligence, incompetence or malpractice or any act of omission liable for disciplinary action by myself or in collaboration with any other person;
8. 9.

That I have not been convicted by a court of competent jurisdiction of any offense involving moral turpitude; That I am fully aware that my failure to notify the PCAB of my disassociation with my present employer shall cause my disqualification to be sustaining technical employee or authorized managing officer or a license applicant with PCAB;

10. That I authorize the PCAB to verify and investigate any or all information in this affidavit from whatever sources PCAB may consider appropriate; 11. That I am executing this affidavit to attest to the truth of the foregoing. FURTHER AFFIANT SAYETH NAUGHT. RODEL B. LACHICA Affiant SUBSCRIBED and sworn to before me this _____ day of ___________________, 20___ affiant exhibited his/her Community Tax Certificate No. _____ issued at __________ ___ on _ . Doc. No. __________; Page No. __________; Book No. __________; Series of 20 ________.

Notary Public
Until December 20 ___

CFY 2011-2012 Type of Application: (Pls. check) New Upgrading x Renewal Others, pls. specify __________________________ __________________________ __________________________
Revised 03/31/04

INSTRUCTIONS ON FILLING UP PCAB FORM NO. 206

QUALIFICATION REQUIREMENTS OF SUSTAINING TECHNICAL EMPLOYEE


1. 2. 3. 4. 5. a) A technology professional, such as engineer or architect, duly license by the Professional Regulation Commission. Holder of Professional I.D. valid for current year. Possesses at least (3) years of experience in implementation of construction to which he is to be nominated. A full-time employee of the nominating contractor, not associated professionally or by employment with any other party, particularly a party engaged in construction or construction-related activities. Have none of the following disqualifications: Involvement, in any capacity, in any construction malperformance of grave consequence, suggestive of his negligence, incompetence and/or malpractice; b) Involvement, by himself or in collaboration with any other person or firm, in any act or omission Liable for disciplinary action of which he or the other person or firm was found g guilty by the Board;

c) Conviction by a court of competent jurisdiction of any offense involving moral turpitude; and d) If formerly a Sustaining Technical Employee or an Authorized Managing Officer of any Construction firm but disassociated there from, failure to notify the Board of his disassociation in accordance with paragraph 5 and 6 of the Affidavit of Undertaking. 6. Not a holder of a contractor's license. If you meet the above requirements, kindly accomplish this affidavit. Erasure must be properly initialed. All statements are subject to verification and any false statement or willful misrepresentation of a material fact in obtaining a license shall be grounds for disapproval of this application.

PASTE PROF. I.D. CARD VALID FOR CURRENT YEAR (Front) (xerox copy)

PASTE PROF. I.D. CARD VALID FOR CURRENT YEAR (Back) (xerox copy)

This is to certify that I have verified with PRC the above stated professional eligibility/registration of the Sustaining Technical Employee. Affiant herein and found the same to be true and correct.

JOHN DEE B. BUSTAMANTE AUTHORIZED MANAGING OFFICER Date: __________________

PCAB Form No. 207 Republic of the Philippines ) Province of AURORA ) Municipality of _BALER_) S.S.

AFFIDAVIT OF STE CONSTRUCTION EXPERIENCE


I, __RODEL B. LACHICA ____, single/married, Filipino, of legal age, with postal address at ____T. MOLINA ST. BALER, AURORA _______, having been duly sworn in accordance with law depose and say that the projects enumerated below constitute my full & complete construction experience.
NAME and COMPLETE ADDRESS of EMPLOYER/ NAME & LOCATION of PROJECTS UNDERTAKEN Work Classification (GE, GB, SP) Nature/Scope of Work Assignment (Proj. Engr.) PROJECT DURATION (mm/dd/yy)

From
JOHN DEE B. BUSTAMANTE CONST. CONCRETING OF ROAD,BRGY. BAGTU,MARIA AURORA, AURORA 935,751.85 JOHN DEE B. BUSTAMANTE CONST. CONCRETING OF ROAD ALONG BALER PUBLIC MARKET, BALER, AURORA 937,594.20 JOHN DEE B. BUSTAMANTE CONST. CONCRETING OF MULTI PURPOSE PAVEMENT, BRGY. OBLIGACION, BALER, AURORA 472,457.47 JOHN DEE B. BUSTAMANTE CONST. CONSTRUCTION OF MULTI PURPOSE BUILDING, BRGGY. SUGUIT, MARIA AURORA, AURORA 1,037,418.60 JOHN DEE B. BUSTAMANTE CONST. REHABILITATION OF BACONG ELEMENTARY SCHOOL, SAN LUIS, AURORA 588,652.02 JOHN DEE B. BUSTAMANTE CONST. CONSTRUCTION 2 CLASSROOM SCHOOL BUILDING, IBUNA ELEMENTARY SCHOOL, DINGALAN, AURORA 1,274,632.79

To

GE-1

PROJECT ENGR.

GE-1

PROJECT ENGR.

GE-1

PROJECT ENGR.

GB-1

PROJECT ENGR.

GB-1

PROJECT ENGR.

GB-1

PROJECT ENGR.

That I authorize the PCAB to verify and investigate any or all information in this affidavit from whatever sources PCAB may consider appropriate; That I am executing this affidavit to attest to the truth of the foregoing. FURTHER AFFIANT SAYETH NAUGHT. Affiant SUBSCRIBED and sworn to before me this _____ day of _________________, 20___ affiant exhibited his/her Community Tax Certificate No. ______________ issued at ___________ ___ on _________________. Doc. No. __________; Page No. __________; Book No. __________; Series of 20 _______. CFY 2011-2012 Type of Application: (Pls. check) New Upgrading

RODEL B. LACHICA

Notary Public Until December 20 ___ Company Name JOHN DEE B. BUSTAMANTE CONST. PCAB License No. ___30458________ x Renewal Others, pls. specify ___________________________ ___________________________
Revised 03/31/04

PCAB Form No. 208

SUSTAINING TECHNICAL EMPLOYEE (STE) PERSONAL APPEARANCE FORM (To be accomplished fully by the STE)

Name: _________RODEL B. LACHICA________________ Sex: _MALE____ Address: ________T. MOLINA ST. BALER, AURORA________________________ Profession: ______CIVIL ENGINEER_______ PRC Reg. No.:_____________ Nominating Firm: __JOHN DEE B. BUSTAMANTE CONSTRUCTION_ Contractor's License No.: __30458_________
I hereby confirm the following: 1. The veracity of the information reflected on the STE Affidavit and Affidavit of Construction Experience (PCAB Form Nos. 107 & 108, copies attached) that I executed in favor of the above firm; 2. That I am fully aware that my failure to notify the PCAB of my disassociation from the above-stated nominating firm and any misrepresentation in the attached forms shall cause my disqualification as sustaining technical employee, or authorized managing officer, or a licensee applicant with PCAB per Board Resolution No. 401, Series of 2001.
3. That I have been previously connected with the following companies: Previous Employers R.L. UMALI CONSTRUCTION N. SOLANO CONSTRUCTION MAKATI DEVT CORPORATION JOHN DEE B. BUSTAMANTE CONST. 4. Other Remarks:
Date of Employment Date of Resignation

Position PROJECT ENG. PROJECT ENG. PROJECT ENG. PROJECT ENG.

01/1998 01/1994 06/1996 07/2002

12/1998 05/1996 06/1998 PRESENT

_____________________________________________________________________________________________________

____________________________________________________________________________________

______________________________ STE's Signature Date Signed: ______________________


Identification Documents Presented:
PRC ID No. 0035428 2. Personal Appearance and Presentation of Two (2) Identification Documents attested by PCAB designated staff or DTI Regional/Provincial Staff valid until 03-11-2013

Drivers License No. NO4-92-227068


valid until _______________

PACITA P. BANDILLA/ Sr. Trade & Industry Devt. Specialist


Signature over Printed Name/Position DTI Office Address: Quezon street, Suklayin, Baler, Aurora Date: ____________________________

PCAB Form No. 204a

LIST OF LAND, BUILDING AND OTHER IMPROVEMENTS OWNED BY AND REGISTERED IN THE NAME OF THE COMPANY AS OF THE BALANCE SHEET DATE

COMPLETE DESCRIPTION (Type of land/building and area)


RESIDENTIAL LAND 365 SQ. M RESIDENTIAL LAND 200 SQ. M COMMERCIAL LAND 1000 SQ. M COMMERCIAL LAND 500 SQ. M RESIDENTIAL LAND 300 SQ. M RESIDENTIAL LAND 240 SQ.M RESIDENTIAL LAND 1,500 SQ.M RESIDENTIAL LAND 11,223 SQ.M

TCT/CCT NUMBER

LOCATION
(St. #, Barangay, Municipality/ City, Province)

ACQUISITION COST

ACQUISITION DATE

T-39446 T-41056 T-42558 T-42559 T-44923 T-44922 T-45158 T-44921

BRGY. SUKLAYIN BALER, AURORA BRGY. SUKLAYIN BALER, AURORA BRGY. RESERVA BALER, AURORA BRGY. RESERVA BALER, AURORA BRGY. ZABALI BALER, AURORA BRGY. ZABALI BALER, AURORA BRGY. RESERVA BALER, AURORA BRGY. PINGIT BALER, AURORA

P100,000.00 P150,000.00 P200,000.00 P100,000.00

DEC.15,2005 DEC.29,2006 JAN.10,2006 AUG.03,200 7 MAR. APR. 11, 2008 FEB. 24, 2009

P200,000.00 26,2008 150,000.00 40,000.00

May be reproduced if necessary

Revised 03/31/04

JOHN DEE B. BUSTAMANTE Signature over Printed Name of AMO

JOHN DEE B. BUSTAMANTE CONSTRUCTION Company Name 30458 PCAB License No. (If applicable) ________________________________________ Date Signed

CFY ___2011-2012

PCAB Form No. 204b

LIST OF DELIVERY AND TRANSPORTATION EQUIPMENT OWNED BY AND REGISTERED IN THE NAME OF THE COMPANY ASOF THE BALANCE SHEET DATE COMPLETE DESCRIPTION
Plate No. ZBN 874 Chassis No. JA 7556 Engine No. WLAT 618816 M.V. File No. ACQUISITION CR No. Date NOV.10,2005 P P 1,26 1,042,453.70 5,00 0.00 520,000.0 436,800 .00 900,000.0 275,000.0 0 1,414,400.00 0.00 756,000 1,301,24 8.00 242,00 Cost

VALUE

BOOK

03860000013 1150 CTK 183 CXZ19J- 10PC103863003505 966073 0000003 7799 RGM FE335E- 4D320386648 460020 9128662 00000 166727 RHZ 884 FV507JX- 6D240386510006 282159 0000018 9821 PAQ 868 KMHJT81 D4HAAU 1340VDBU122 239209 0000044 566 3675

RES 626 NKR66E- 4HF17482552 420223

5202306 AUG.3,2007 -4 1972225 AUG.3,2007 1 6408746 DEC.1,2008 -1 8359891 APRIL 04, -1 2009 1123939 Sept. 1 06,2010

0 0

.00

1,336,000.00

1,291,466. 67

TOTAL

P P 5,710,400.00 5,069,968.37

LIST OF MACHINERIES/PLANTS AND OTHER CONSTRUCTION EQUIPMENT OWNED BY THE COMPANY AS OF THE BALANCE SHEET DATE COMPLETE DESCRIPTION

SERIAL NO.

ACQUISITION Date Cost P

VALUE

BOOK

TCM PAY LOADER KOMATSU EXCAVATOR BAGGER MIXER CONCRETE SCREEDER CONCRETE VIBRATOR VIBRATORY COMPACTOR WATER PUMP CONCRETE CUTTER ROAD ROLLER CONCRETE MIXER MITSUBISHI MOTOR GRADER

75B-0727 PC200-1 16944818 61644867

SEPT.19,20 06 JUL. 28,2007

0021 CXZ71J-3007421 MG3-185743

SEP. 09, 2009 NOV. 12, 2009 DEC. 01, 2009

P P 650,000.00 563,333.33 P1,100,000. 990,00 00 0.00 40,000 24,00 .00 0.00 15,000 9,00 .00 0.00 16,120 10,40 .00 5.33 7,500 4,60 .00 0.00 10,000 6,50 .00 0.00 13,500 8,77 .00 5.00 496,400. 479,853 00 .33 1,140,000. 1,102,000. 00 00 1,560,000. 1,508,000. 00 00

TOTAL

P P 5,048,520. 4,706,466. 00 99
Revised 03/31/04

May be reproduced if necessary

JOHN DEE B. BUSTAMANTE Signature over Printed Name of AMO JOHN DEE B. BUSTAMANTE CONSTRUCTION Company Name 30458 PCAB License No. (If applicable) ________________________________________ Date Signed

CFY 2011-2012

PCAB Form 111-A (For sole proprietorship)


Republic of the Philippines) s.s. Province of Aurora )

AFFIDAVIT
I, JOHN DEE B. BUSTAMANTE, of legal age, Filipino, married/single with postal address at 80 Buton St. Sitio Labasin, Brgy. Sabang, Baler, Aurora, after having been sworn to in accordance with law, hereby depose and say:
1. That I am the Proprietor/Authorized Managing __________________________________________________________; (Name of Firm) Officer (AMO) of

2. That I appoint ____________________________, whose picture and signature appear below, to transact business with PCAB; i.e, present for pre-screening my application for contractors license or any application related thereto, file/follow-up, submit documents, receive notices/license in connection with the said application and the like.

Passport size Picture of Representative

______________________________ (Signature over Printed Name of (representative) ______________________________ ______________________________


COMPLETE HOME /MAILING ADDRESS

3. That I am aware that I am responsible/liable for any or all acts/representation made by my representative in connection with the functions stated herein. 4. That I undertake to notify PCAB in the event that this appointment is modified, amended or revoked.

JOHN DEE B. BUSTAMANTE AFFIANT

SUBSCRIBED and sworn to before me this ______ day of ____________,20___, affiant exhibited his/her Community Tax Certificate No. 12553485 issued at Baler, Aurora on January 5,2010.
Doc No. __________ Page No. _________ Book No. _________ Series of _________ Notary Public Until December 20 ___

(Note: Please submit original and one duplicate to PCAB. Keep another copy for presentation every time you transact with PCAB)

PCAB Form 111-B (For corporation, partnership, cooperative joint venture or consortium)
Republic of the Philippines) s.s. _______________________)

AFFIDAVIT
I, _______________________________, of legal age, Filipino, married/single with postal address at ____________________________________, after having been sworn to in accordance with law, hereby depose and say:
1. That I am the Authorized Managing ________________________________________; (Name of firm) 2. Officer (AMO) of __________

That the above stated firm had duly appointed ____________________________, whose picture and signature appear below, to transact business with PCAB; i.e, present for pre-screening its application for contractors license or any application related thereto, file/follow-up, submit documents, receive notices/license in connection with the said application and the like. ______________________________ (Signature over Printed Name of (representative) ______________________________ ______________________________
COMPLETE HOME /MAILING ADDRESS

Passport size Picture of Representative

3.

That we are aware that we are responsible/liable for any or all acts/representation made by the above representative in connection with the functions stated herein.

4. That the firm undertakes to notify PCAB in the event that this appointment is modified, amended or revoked.

____________________________________
AFFIANT

SUBSCRIBED and sworn to before me this ______ day of ______________, 20__ affiant exhibited his/her Community Tax Certificate No. _______________ issued at ___________ on ___________________.
Doc No. __________ Page No. _________ Book No. _________ Series of _________ Notary Public Until December 20 ___

(Note: Please submit original and one duplicate to PCAB. Keep another copy for presentation every time you transact with PCAB)

PCAB FORM 205

STATEMENT OF ANNUAL VALUE OF WORK ACCOMPLISHED As of the year ending 2010


PROJECT PARTICULARS: 6 4 5 REHABILITATION OF BACONG ELEMENTARY SCHOOL CONSTRUCTION OF 2 CLASSROOM SC HOOL BUILDING

Title of project:

CONSTRUCTION OF MULTI PURPOSE BUILDING

Project owner: Location:

DPWH-AURORA BRGY. SUGUIT, MARIA AURORA , AURORA

DPWH-AURORA SAN LUIS, AURORA

DPWH-AURORA IBUNA ELEMENTARY SCHOOL, DINGALAN, AURORA

Classification/Total Cost :

GB-1

/ 1,100,000.00

GB-1

/ 600,000.00

GB-1

/ 1,300,000.00

CONTRACT PARTICULARS Date of contract: Contract completion time : Scope of work: Amount of contract: Name of Main Contractor or Joint Venture Partner, if any:
MARCH 24, 2010 JUNE 23, 2010 MAIN CONTRACTOR 1,037,418.60 JOHN DEE B. BUSTAMANTE CONSTRUCTION MARCH 22, 2010 MAY 07, 2010 MAIN CONTRACTOR 588,652.02 JOHN DEE B. BUSTAMANTE CONSTRUCTION MARCH 24, 2010 MAY 24, 2010 MAIN CONTRACTOR 1,274,632.79 JOHN DEE B. BUSTAMANTE CONSTRUCTION

WORK ACCOMPLISHMENT

As of start of year: As of end of year :

______________ %_____ __________________ %100

______________ %_____ ____________________ %100

_____________ %______ __________________ %100

TECHNICAL EMPLOYEE(S) Name and Profession: Position Title:


RODEL B. LACHICA CIVIL ENGINEER RODEL B. LACHICA CIVIL ENGINEER RODEL B. LACHICA CIVIL ENGINEER

PROJECT ENGINEER

PROJECT ENGINEER

PROJECT ENGINEER
Revised 03/31/04

*** NOTES: See instructions at the back before filling up this form. This may be reproduce if necessary. ***

JOHN DEE B. BUSTAMANTE Signature over Printed Name JOHN DEE B. BUSTAMANTE CONSTRUCTION Company Name 30458 PCAB License No.

PCAB FORM 205

STATEMENT OF ANNUAL VALUE OF WORK ACCOMPLISHED As of the year ending 2010


PROJECT PARTICULARS: 9 7 8 CONSTRUCTION OF BOX CONSTRUCTION OF CULVERT BOX CULVERTGOING TO HACIENDA ELEMENTARY SCHOOL DPWH AURORA DPWH AURORA BRGY. NONONG, SAN LUIS, AURORA

Title of project:

CONSTRUCTION OF MULTI PURPOSE BUILDING DPWH AURORA

Project owner: Location:

BRGY. DIOME, MARIA SAPANGKAWAYAN ELEMENTARY SCHOOL, AURORA, AURORA DIPACULAO, AURORA

Classification/Total Cost :

GB- 1

/ 353,350.00

GE-2

/945,000.00

GE-2

/ 500,000.00

CONTRACT PARTICULARS Date of contract: Contract completion time : Scope of work: Amount of contract: Name of Main Contractor or Joint Venture Partner, if any:
MARCH 24, 2010 MAY 04, 2010 MAIN CONTRACTOR 346,791.82 JOHN DEE B. BUSTAMANTE CONSTRUCTION MARCH 24, 2010 JUNE 08, 2010 MAIN CONTRACTOR 932,204.00 JOHN DEE B. BUSTAMANTE CONSTRUCTION MARCH 24, 2010 MAY 06, 2010 MAIN CONTRACTOR 451,792.57 JOHN DEE B. BUSTAMANTE CONSTRUCTION

WORK ACCOMPLISHMENT

As of start of year: As of end of year :

______________ %_____ __________________ %100

______________ %_____

_____________ %______

_____________________ ___________________ %100 %100

TECHNICAL EMPLOYEE(S) Name and Profession: Position Title:


RODEL B. LACHICA CIVIL ENGINEER RODEL B. LACHICA CIVIL ENGINEER RODEL B. LACHICA CIVIL ENGINEER

PROJECT ENGINEER

PROJECT ENGINEER

PROJECT ENGINEER
Revised 03/31/04

*** NOTES: See instructions at the back before filling up this form. This may be reproduce if necessary. ***

JOHN DEE B. BUSTAMANTE Signature over Printed Name JOHN DEE B. BUSTAMANTE CONSTRUCTION Company Name 30458 PCAB License No.

PCAB Form No. 207 Republic of the Philippines ) Province of AURORA ) Municipality of _BALER_) S.S.

AFFIDAVIT OF STE CONSTRUCTION EXPERIENCE


I, __RODEL B. LACHICA ____, single/married, Filipino, of legal age, with postal address at ____T. MOLINA ST. BALER, AURORA _______, having been duly sworn in accordance with law depose and say that the projects enumerated below constitute my full & complete construction experience.
NAME and COMPLETE ADDRESS of EMPLOYER/ NAME & LOCATION of PROJECTS UNDERTAKEN Work Classification (GE, GB, SP) Nature/Scope of Work Assignment (Proj. Engr.) PROJECT DURATION (mm/dd/yy)

From
JOHN DEE B. BUSTAMANTE CONST. CONSTRUCTION OF MULTI PURPOSE BUILDING, SAPANGKAWAYAN ELEMENTARY SCHOOL, DIPACULAO, AURORA 346,791.82 JOHN DEE B. BUSTAMANTE CONST. CONSTRUCTION OF BOX CULVERT, BRGY. DIOME MARIA AURORA, AURORA 932,201.00

To

GB-1

PROJECT ENGR.

GE-2

PROJECT ENGR.

JOHN DEE B. BUSTAMANTE CONST. CONSTRUCTION OF BOX CULVERT GOING TO HACIENDA ELEMENTARY SCHOOL, BRGY. NONONG, SAN LUIS, AURORA 451,792.57 JOHN DEE B. BUSTAMANTE CONST. CONSTRUCTION OF FLOOD CONTROL, BRGY. DIAAT, MARIA AURORA, AURORA 935,805.10 JOHN DEE B. BUSTAMANTE CONST. CONCRETING ROAD, BRGY.MALIGAYA, DIPACULAO, AURORA 918,968.56 JOHN DEE B. BUSTAMANTE CONST. CONCRETING ROAD, (SO LIBIS, PUROK 02), BRGY. BUHANGIN, BALER, AURORA 998,042.34

GE-2

PROJECT ENGR.

PROJECT ENGR.

GE-1

GE-1

PROJECT ENGR.

GE-1

PROJECT ENGR.

That I authorize the PCAB to verify and investigate any or all information in this affidavit from whatever sources PCAB may consider appropriate; That I am executing this affidavit to attest to the truth of the foregoing. FURTHER AFFIANT SAYETH NAUGHT. Affiant SUBSCRIBED and sworn to before me this _____ day of _________________, 20___ affiant exhibited his/her Community Tax Certificate No._______________ issued at _______________on _______________. Doc. No. __________; Page No. __________; Book No. __________; Series of 20 _______. CFY 2011-2012 Type of Application: (Pls. check) New Upgrading

RODEL B. LACHICA

Notary Public Until December 20 ___ Company Name JOHN DEE B. BUSTAMANTE CONST. PCAB License No. ___30458________ x Renewal Others, pls. specify ___________________________ ___________________________

Revised 03/31/04

PCAB FORM 205

STATEMENT OF ANNUAL VALUE OF WORK ACCOMPLISHED As of the year ending 2010


PROJECT PARTICULARS: 12 10 11 CONCRETING OF BRGY. CONCRETING OF ROAD ROAD

Title of project:

CONSTRUCTION OF FLOOD CONTROL

Project owner:
DPWH-ADEO DPWH-ADEO

MUNICIPAL GOVERNMENT OF AURORA SO LIBIS, PUROK 02, BRGY. BUHANGIN, BALER, AURORA

Location:

BRGY. DIAAT, MARIA AURORA, AURORA

BRGY. MALIGAYA, DIPACULAO, AURORA

Classification/Total Cost :

GE- 2

/ 945,000.00

GE-1

/945,000.00

GE-1

/1,000,000.00

CONTRACT PARTICULARS Date of contract: Contract completion time : Scope of work: Amount of contract: Name of Main Contractor or Joint Venture Partner, if any:
MARCH 24, 2010 MAY 24, 2010 MAIN CONTRACTOR 935,805.10 JOHN DEE B. BUSTAMANTE CONSTRUCTION MARCH 24, 2010 JULY 01, 2010 MAIN CONTRACTOR 918,968.56 JOHN DEE B. BUSTAMANTE CONSTRUCTION 998,042.34 JOHN DEE B. BUSTAMANTE CONSTRUCTION MARCH 25, 2010 FEBRUARY 01, 2011

WORK ACCOMPLISHMENT

As of start of year: As of end of year :

______________ %_____ __________________ %100

______________ %_____

_____________ %______

_____________________ ___________________ %100 %100

TECHNICAL EMPLOYEE(S) Name and Profession: Position Title:


RODEL B. LACHICA CIVIL ENGINEER RODEL B. LACHICA CIVIL ENGINEER RODEL B. LACHICA CIVIL ENGINEER

PROJECT ENGINEER

PROJECT ENGINEER

PROJECT ENGINEER
Revised 03/31/04

*** NOTES: See instructions at the back before filling up this form. This may be reproduce if necessary. ***

JOHN DEE B. BUSTAMANTE Signature over Printed Name JOHN DEE B. BUSTAMANTE CONSTRUCTION Company Name 30458 PCAB License No.

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