Resolution 6869 - Laserfiche WebLink

SMALL WORKS STA *6oF STAT EMENT OF INTENT TO PUBLIC WORKS CONTRACT PAY PREVAILING WAGES ($2,500 or less including tax) .189 apY AND D This form must be typed or printed in ink and completed in full or it will be returned or oIDAVIT OF WAGES PAID Large, bold numbers match instructions on lite back of this form. Shaded areas are for the Awarding Agencyand Labor &Industries (L&I) use onlya No filing fee Contractors 'nay obtain this form from the CONTRACT AWARDING AGENCY only. Contractor's must complete and return the form to the CONTRACT AWARDING AGENCY. If the agency approves the form, it will send a co approved form to L&I within 30 days of the date the a en cy received the form from the contractor, copy of the 1 ConVct A%rding Agency l j . � r"`' Project Name A,tarding Agency Address ` Contractor Purch se Order Number Cit}State ZIP+4 ` 1, 011 t.r t c County miere Work yVas Performed City Where tVork \il ed Indicate Total Dollar Amount of Your Contract - Include Sales Tax ' 1) �i r VI , l- t (No "Ti „e R Materials" allowed) Date Contract Agar ed (inn!/dd/yy) Date,Work Completed (corn/dd/yy) Number of 0!!ner/Operators who ogre at least 3090 of the company who performed work on '' this project: (check one box) None (0) 0 .One (I) ❑ T\Yo (2) ❑ Three (3) J Did employees perforin aorl: on this project? (check one box Yes El No (If "Yes" - please list below) C'rai'ts/I'rades/Occupations and Apprentices – For Apprentices enter U U 0 the name, registration number, trade, dates !wrl;ed on project, static Number 7 Dial / of Rale of 3 of progression, rrr.ge ant usual benefit for each apprentice, of 1i'orkers hours 1Vorked Rate (" ri nre} Floirl}" Usual ("Fringe^) in Each Trade in Each Tr.^.de 1i'^s Bene lits r g } Contractor Address Contractor Phone N miter Contractor E-mdil Address j City State �°' � � t � `�.�. fi �' c in ritLt))` �i�'�.�.!� Contractor Registration Number Co ractor UB[ Number ;�a'` Contractor Industrial Insurance Account Number 1�' GL` rr I hereby certify that the above information is correct and that all a Ler [employed on this Pu licl�fl'orls(Project were paid no less than tlrc Prevailing 1/'age rates) as determined by the Industrial Statistician of the Department of Labor & industries. [understand that contactors who violate Prevailing Wage laws, e.g., apply incorrect classifications/scopes of work for tnsts performed on the project, fail to pay correct prevailing tivrrge rates, ere., are subject to fines and/or eb rnreut and will be re uired to ra an back wa es ue wm kers, See RC\v 39,12.065. Contractor Signature – Date f 5� e/ Title �� PLEASE NOTE: —� � � :i t�') • ht approving this roan, the Awarding Agency must verify that the Contractor's Registration or License is current and valid. • 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 publicworks project of more than thousand five hundred dollars for the purpose of circumventin the rocedures re uired b hvo RCW 39.12.040 I . Approval: Name and Title of Individual Authorized to Approve This Form Phone Number - on Behalf of the Awarding Agency (type or print) Email Address IO — -19-1 lr-e ur rnurvraual Authorized to Approve This Form on Behalf of the Awarding Agency Date Received: Department of Labor & Industries Date: F700-106-000 Combined Intent & Affidavit— Small Works — ($2,500 or less) 09-2010