Lakeside Industries, Inc. 5/3/2024

This form must be submitted with the Bid Proposal or as a Supplement to the Bid no later than 24 hours after the time for delivery of the Bid Proposal, as provided for in Section 1-02.9 of the Contract Provisions. Certification of Compliance with Wage Payment Statutes The bidder hereby certifies that, within the three-year period immediately preceding the bid solicitation date (April 2, 2024), the bidder is not a “willful” violator, as defined in RCW 49.48.082, of any provision of chapters 49.46, 49.48, or 49.52 RCW, as determined by a final and binding citation and notice of assessment issued by the Department of Labor and Industries or through a civil judgment entered by a court of limited or general jurisdiction. I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Bidder’s Business Name Signature of Authorized Official* Printed Name Title Date City State Check One: Sole Proprietorship ☐ Partnership ☐ Joint Venture ☐ Corporation ☐ State of Incorporation, or if not a corporation, State where business entity was formed: If a co-partnership, give firm name under which business is transacted: * If a corporation, proposal must be executed in the corporate name by the president or vice-president (or any other corporate officer accompanied by evidence of authority to sign). If a co-partnership, proposal must be executed by a partner. 2024 Pavement Maintenance Overlay PROPOSAL: CERTIFICATION OF COMPLIANCE WITH WAGE PAYMENT STATUTES PW# 3823 March 6, 2024