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SMALL WORKS MAMN STAI AkiNT OF —PMNT TO <br />PUBLIC WORKS CONTRACT 4% <br />($2,%0 ©r hm including tax) PAY PREVAMMG WAGES <br />AND <br />AFFIDAVIT OF WAGES a a All <br />" <br />This farm mug be tMped or Wided ®ick and cwVjeftd in fi,11 or — or W"ec�bm��� <br />f <br />it vn7U b,� refused for correction. <br />Law- bold atmobus match iUMmedions -M Me back of d4is fom- SM&A m=!asave Kw the Awa <br />Agewy and tabor &hWwmncs (IAI) use ady 140 filing fee <br />CGRU'aaars D=y obtain this form from the CORhU iCTAW�ARDMZ AGENCY only. Contractors Must comOete and <br />return the famin to the CONTRACT AWARMG AGENCY. tithe agency "proves the form, it WE send a copy of the <br />approved form In Leet widda 30 days of the date the agmey received the <br />Ul Coubma A- rowed Name form from the cmtracto,- <br />C"*Ma rrr PRIChsse Ckdff Munber <br />SWC ZIP -5-4 <br />C—AY**t 2S <br />CivWwat <br />,° D <br />(NO-U-w ) weC,WaqAw(mm=AWyy) ww perjumm <br />D <br />$ <br />Member of <br />ow-130mam whoe"M 21 kat 30%,fd", <br />this P-ject (dw&aw box) 0 New (0) 00-(t) [JT.(2) (3) <br />Dd a pin,. pr. asad . g. p�jeat,, -- <br />CraftVTr*des,0mwp2dm 2nd rwtk. - F. Appmadm ea <br />dor -Mt, rfPsb�2boa aerie r, tsde, d, Jes Uvrw On Project, <br />UNw— <br />Number <br />Tataffef <br />Ralref <br />RateerHourly <br />*fpn*XrsdGa, and USMI benefit 1w curb 2""86M <br />efwwLffs <br />in FAA Trade <br />Henry weart" <br />HQzrkF <br />t%WA rFi*ge-) <br />is Ea& Tr=Ie <br />IV --es <br />COMbactm <br />0 It 77, <br />C -&--W E -a Ad&Caty <br />- <br />ZV4 <br />J <br />e, I- - <br />1 b --b- Cc -"Y Xbowe kFarmafim is tsjjj�cj end 1bt 29 wertm i -D*Ytd on this W-11, P-jw P. -d On 1,!F,. &. &� <br />P -AT -9 Iva_-_ '-'*I " *111a by Ae 1-6ww Sftfisfi&a of tine Dqft..t Of Lb.,,& 1 A.3ft" 06at C It Fie Y%kqr <br />Prewaffin IVVE Izas. t -f- spoy iarwrcct mf ry orf for <br />ftsU 1"'w"" OR ffte fwv!ie&, f3M to pay <br />be --qmr" so my An ba& EVE$ co r-' P- --ra <br />See RM 39-0-K& <br />7/1 <br />In 2PP"MM9-' d= ire, 6, Aww4kg Amency <br />-Awl We* *w dw CO3U&-jw-S R4g,*,R,, Is CIMMS Zed 13M <br />• -* w bar -..* M. -M . ja &e A—ding A <br />Fix -110-a�mn an PM-" A--d-g A --.y b&dty .Wdg _wwy- no Mb0Mta,,, <br />• ItCW 39-12-0442Xtt NdWAg in &S sea&, SkM be m&,WW t, a OR kRw sw RCW 39 12-040(2)(d� <br />&jwMj kw bwdmj SAME &, d* Aawy <br />TT22L!rTM 0 sdmr"k R"y PUUj-- -wh P-jea e(mare am fte <br />es by WS, 39-12- <br />PbVwNwwjMr -i� <br />oxr Bebaffeffhe 14-rdmg A --y (p" p.0) I TE.;- <br />Skanture of L'Aw"W4Aatbsrrzed to Awe �TVn Form *0 <br />Aw-IftZ Agenqw <br />Received. %Part�t of�Uhu, &�Idast�,j,5 <br />F7WI06-W CGRIbimed Inkit& Affidavit-SaWl Wucks-($_2_5(MoF&- <br />.ss) W2010 <br />