Resolution 6871 - Laserfiche WebLink

SMALL, WORKSsT^r� STA1 EMENT OF INTENT TO PUBLIC' WORKS CONTRACT . �� r. PAY PREVAILING WAGES FAgency 00 or less including tax) °� �2� AND m must be typed orfrinted in ink ani—cm mpleted in full or it will be retutnedfor f r correction. OF WAGES PAID old numbers snatch instructions on the back of this form. Shaded areas are fol the Alvarding and Labor &Industries(L&I) use only. No filing fee Contractors may obtain this form from the CONTRACT AWARDING AGENCY only. Contractors must connplete and return the form to the CONTRACT AWARDING AGENCY. If the agency approves the form, it will send a copy of the a roved form to L&I within 30 days of the date the enc received the form from the contractor. I Con Tact A1ding Ageucy q,�ejct Name i' U . xf A NN i i. f 41 ` :A1larding Agency Address 4Y Tip)tract or Purchase Order Nu bCityState ZIP+4 ty \t1here 11'ork yYas Performed City Where Wort: Was Performed Indicate Total Dollar Amount of your Contract -IncldeSatesT(No fi-p & Materials" allowed) Contract Awarded (mm/dd/yy) Date/Work or pieted (mm/dd/yy) '2 23 L qJ1 7/1 Number of ON1 nee/Operators who own at least 30 of the company who perfonned work on this project: (check one box) ❑ None (D) Of --O' (t ) El Two (2) ❑ Three (3) Did employees perform work on this project? (check one box Yes ❑No (If ")'es*'- Please list below)----'-- Craftsff•rades/Occrr tions and Appi e!iiiees— For A n lren(ices enter U U O Pa I I Nnmber 3 the name, registration number, trr:de, dates vorked on project, shzge Total K of Rate of t of progression, wr,gc :rd usual benefit for each npprentiee. ofl, Hours 11'm ked t,ztc of Hourly Elouwt in Each Trade y Usual ("Fringe in Erclr il:nde 11'a es � D - netits Conipatiy I.ratae Contractor Address — � . •salt soft[.. A Contractor Phone N unber Contractor Email Address ` I r City State > 0�` " Zlf+4 Al i F�,� i,►,s}. (1�"1 +�t Contractor Registration Number " rJ i Cot ractorUBINumber L itri ! , ( (►� rF�"" Contractor Industrial Insurance Account Number ti r ` (t'j,--- s)•.'r... ^,"�4�is �,.. 4'f '1 I hereby certify that the above information is correct and that nll workers I employed on fills ,Pu� lic�l}'o,Irs project mete paid no less than the Prevailing wage ratc(s) as deternnined by the Industrial Statistician of the Department of Labor & Industries. I understand that contractors 11.110 violate Prevailing Wage talus, ag., apply incorrect classifications/scopes of 1va•h for ptslcs performed on the project, fail to Pay correct prevailing lrage rotes, etc., are sub'ect to fines and/CLIrt 70,, twill be required to nn an back nva es due ortccrs. See RCW 39.12.t)G5. Contractor Signature Date Title PLEASE NOTE: r) • ht approving this form, the Anvarding Agency must verify that the Contractor's Registration or License is current and valid. • The contract dollar amount indicated shalt 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 pubiwrks project of nnore than two thousand five hundred dollars for the purpose of circunnventin r the Procedures uired by RCW 39.12.040 1 . I O Approval: Name and Title of Individual Authorized to Approve This Form I Phone Number on Behalfof the Awarding Agency (type or print) Enialt Address Signature of Indtvidual Autbortzed 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