Resolution 6964 - Laserfiche WebLink

SMALL WORKS s STA: oma TS STATEMENT OF INTENT TO ,,•� x PUBLIC WORKS CONTRACT1 t PAY PREVAILING WAGES ($2,500 or less including tax) o' ''0.4 "� AND AFFIDAVIT OF WAGES PAID This form must be typed or printed in ink and completed in full or it will be returned for conection. Large,bold numbers match instructions on the back of this form.Shaded areas are for the Awarding No filing fee Agency and Labor&Industries(L&I)use only. Contractors may obtain this form from the CONTRACT AWARDING AGENCY only.Contractors must complete and return the form to the CONTRACT AWARDING AGENCY.If the agency approves the form,it will send a copy of the approved form to L&I within 30 days of the date the agency received the form from the contractor. UConSract A din Agency Pr ject Name CI o EUCTC‘\- irc��t Ow beerZlll e, !b7o� lei l yAwarding Agencyon Address Ct or Pdrehase Order Number '3200G- ,e,Ar 5l~ W / 3-2 as-- City Sta e Z Co my ere Work'Vas Perfonned City Where Work W as PerformedFvc V U 2t1 toorvtiItc. k,i- Indicate Total Dollar Amount of Your Contract•Include Sales Tax Date Contract Awarded (mm/dd/yy) DateaW rk Co pleted (mm/dd/yy) (No"Time&Materials"allowed) 4.7t o 8 /2-/// /4~ i/z5.-/(4, 02 Number of Owner/Operators who own at least 30%of the company who performed work ofi this project: (check one box) ❑None(0) One(1) 0 Two 2 O ❑Three(3) 03 Did employees perform work on this project? (check one box) IYes ElNo (If"Yes"-please list below) ® O © 0 ti Crafts/Trades/Occupations and Apprentices—For Apprentices enter Number Total#of Rate of Rate of Hourly the name,registration number,trade,dates worked on project,stage of Workers Hours Worked Hourly Usual("Fringe") of progression,wage and usual benefit for each apprentice. in Each Trade in Each Trade Wages Benefits ertN104\ LC\94( -?.- 12..- 4LAI _ 0— 4C racto Comp yN e Contractor Address 1/4...trANIni.el' V.QTYrt‘rtVw, TM:, +M. & fivi:ISv‘\ (1 ., 54tAi. , Contractor Phonember Contractor Email Address City State ZIP+4 1/4h f-(At- 1.30> 9 eta 5 s.+.i c �l um MAL\kt, levet . 962,7.`"' C trractor Registration Number ContractorCo UBI Number Contractor Industrial Insurance Account Number CttfIlIG IC.l e,)13.Nt' 403-117- 48 7.11/4. IY6-0C I hereby certify that the above information is correct and that all workers I employed on this Public Works Project were paid no less than the • Prevailing Wage rate(s)as determined by the Industrial Statistician of the Department of Labor&Industries. I understand that contractors who violate Prevailing Wage laws,e.g.,apply incorrect classifications/scopes of work for tasks performed on the project,fail to pay correct prevailing wage rates,etc., are subject to fines and/or i eb rment and will be required to pay any back wages due workers.See RCW 39.12.065. Contractor Signature \4 Date Title kAy8PLEASE NOTE: _adais•I. . liZ 0 - I • In approving this form,the Awarding Agency must verify that the Contractor's Registration or License is current and valid. o The contract dollar amount indicated shall only be for a single payment in full on a single contract with the Awarding Agency.NO subcontractors. • For information on potential Awarding Agency liability regarding use of this alternate filing process,see RCW 39.12.040(2)(d).: • RCW 39.12.040(2)(e):Nothing in this section shall be interpreted to allow an Awarding Agency to subdivide any public works project of more than two thousand five hundred dollars for the purpose of circumventing the procedures required by RCW 39.12.040(1). kill Approval:Name and Title of Individual Authorized to Approve This Form Phone Number Email Address on Behalf of the Awarding Agency(type or print) • Signature of Individual Authorized to Approve This Form on Behalf of the Date Awarding Agency Received: Department of Labor&Industries Date: . F700-106-000 Combined Intent&Affidavit—Small Works—($2,500 or less) 09-2010