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SMALL WORKS �£ 5T"rEoSTA'1 EMENT OF INTENT TO PUBLIC WORKS CONTRACT � b �yy PAY PREVAILING WAGES •d N ($2,500 OF less including tax) w� - �2 AND yI88a �DY D AFFIDAVIT This form must be typed or printed in ink and completed in full oil"], will be returned for correction, OF WAGES PAID Large, bold numbers match instructions on the back_ of this fot•m. Shaded areas are for the Awarding Agency and Labor &Industries (M) use only. b No filing fee Contractors may obtain this form from the CONTRACT AWARDING AGENCY only. Contractors must complete anti return the form to the CONTRACT AWARDING AGENCY. If the agency approves the form, it will send a copy of the approved oved form to L&I within 30 days of tilt (late thea eney received the form ft ora the contractor. Con ract Asrdin3Agency ` 1`j t.i.° Project Name AwardingrAgency Address LICirb Ckc.I1r1-- i� Contract or Purchase Order umher Q l l Cn[) State 7_IP+4 County Where Work Nk'as Perforated City Where Work Was Perfonned i ( Indicate Total Dollar Amount of Your Contract - Include Sales Tax 1 tt (I e � (No"Ti—r R Materials" allowed) Date Co tract Awarded (mm!dd/yy) Dale'Wor • C ntpleted (mm/dd/yy) Number of Oe era( who own at least 30% of the company who performed work on this project (check one boxx)) ❑NomO Il (�.Onz (I) ❑ Two (2) ❑ Three (3) 3 Did employees perform work on this Project? (check one box) Yes ❑No (Ill - please list below) C"raftsli'i•ades/Occupations and Apprentices - For Apprentices enter Number the name, registration number, trade, dates worked oil project, st::oeI in uher of progression, wage and usual beac5t for each ; p rendee, �� of ach Trrs 7— Total # of Itntr of Hours kk'orked EIoui-ly in rnch Trade Wages y Rate of Hourly Usual ("Fringe") Benefits 12T C lrr iot Comp��. qity N e\ Contractor Address Contractor Phone Npmber Contractor Email Address(` y State Q ) Cil S a e '� fir""'y.,. )) 4 zipl+4 t Clt - �{(�,c'iRilttOf. ��hR.t �1s� d3lt�� Contractor Registration Number Co raclor UBI Number / Contractor Industrial Insurance Account Number 1 hereby certifo y that the deter information is Prevailing Wage rind thtt all eorkeis i employed on this Pu lie Wotics Project were paid no less than the ge rates) as determined by the Industrml Statistician of the Department of Lahm• d;: Industries. 1 understand that conh•actm's who violate Prevailing Wage laws, e.g., apply incorrect classifications/scopes of work for taslis performed on the project, fail to pay correct prevailing wage rates, etc., are subject to fines and/or eba ruent and t -111 be required to a an back wa es di e w rker•s. Sec R 11'39.12.065. Contractor Signature 1 Date 'title FLEASE NOTE: —�---77777,5, _ _ S • In approving this form, 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 A%arding Agency, NO subcontractors. • For information on potential Awarding Agency liability regarding use ot•this alternate filing process, see RCW 39.12.040(2xd). • RCW 39.12.040(2)(e): Nothing in this section shall be interpreted to allow an Awarding Agency to subdivide any publ thousand five hundred dollars for the Purpose ofcircurnventing the procedures required by RCW 39.12-040(1). ic works project of more than hvo !J0 Approval: Name and Title of individual Authorized to Approve This Fonn Phone Number on Behalf of the Awarding Agency (type or print) Email Address Signature of Individual Authorized to Approve This Form on Behalf Awarding Agency Date: Date Received: Department of Labor & Industries F700-106-000 Combined Intent & Affidavit— Small Works — ($2,500 or less) 09-2010