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3 <br />OAK AT T xU&-%- i xrcr <br />lo1T OF <br />PL%UC WORKS CONTRACT PAY PREVAH NG WAGS <br />($2,500 Or &M including tax) <br />AND <br />AFMAM OF WAGS PAID <br />This farm twist be typed or plias ad in int and cotgtletcd in fan of it w7 be nfwtted for eaneraion. <br />Lange, bold woolmn natcb ins(nw1kn s an the batt of this form. Awed areas at: Fargo Awarding NO Wing �ffee <br />and Labor Madoskies <br />am o�y <br />C"hvctois may abds this born fiom the CONTRACT' AWARDING AGENCY omit,%, C =bm ns wast eon1Plt�e iwid <br />rehwu the fauns to the CONTRACT AWARDIi G ACBNCY. Woe agency apprntns the Totrw, it Wo yend a copy of the <br />form to T.AT n-- 30daysaftheldhate theagency received the for= from the endrmta,; <br />iU <br />LAOT bz. <br />Ate Ce011xeert'lridaaset3aierMomber <br />15j 3 <br />tits She: Z11144 _ I <br />ILI <br />ieiirelieTetd DelhrAsmief ttfYonrQortxt • LrlsdeSc3esTa <br />(tdo -r. � llfaiaiak atbaod Oak CW*&I A-wM ( yy) VAk <br />® Ho baofOnwaoUperaldsuioa®rtleastWA*fthe LO° ' n1°0 Paieo"ai wk e" <br />this pawjact (vtack eoo boot) � <br />(Imme (0) O of (1) ❑ ❑ 7 T.(2) m (3) <br />® Did empley� perkirra nal; mi dw pmjM? (dvxk acre baa) Ya o (If"Yt�' - plrite fist 6ei"a� <br />Cr�£rades1 ccsp2fwas and Ap Apprentices- Fur AWra&]yces eater ®r <br />the same, registration numbe , trade, dates truths as t� Ram hate of Hourly <br />p 'eofii Dries s HHeady tlssat (-Fringe') <br />tel F Win. awe and usual beae5t far each apprer cn in Eu h Tracie <br />"19t <br />in2 �Y lime6tsl <br />Comer Addrew <br />Ceo�cter4P Pbonc tkinbeir` cadradorl3mac7Address City F state iota <br />CA <br />vt <br />Cad>ad"Rgoskwj Number C e U81 tJmnber Caerackw ladtastrid fnsoni a Account I <br />1 berri5g ccr6fy that the above iatamaGea is correct cud Haat a11'trorixrs [ esalda}ed an this Pa it 1Yorf Prefect u'e.- paid — less than the <br />Pnwmffing 1Pase =I*) as dz4erm111cd by the Industrial Si2fsfi&311 of the Deywrtmrst d Labor & Industri 1 <br />m understand that cojk-reton who violate <br />Paccar' g Wage laws, ea, apply incorrect classifiicatwnslseoPes of Werk far tasks performed on The ect fsil to <br />I'n'! <br />par correct prcrai6aa wee races, etc, <br />I" subject to fines An", -moat and Will be r ed to an back a <br />Coottader Sime ? a Warier&. See RCW 39.1? 965, <br />Date _ <br />PLEASE KCF <br />° to 2111%Pniog dais fames, Qae Awarding Agency rant iro* dad dee Contractor's Regist 3tim Cr taeease is c®r®i amt &.alis <br />a The ccalract doflar amooW used *a** be fora siajje Mma`t m (tall nA a SJagle <br />ecvArad nide the: A <br />rardiag ° Far isfarrnation ea patcatial Awardi� Ar-ptnty tiablTity � rise aftl� aRanate Agency- Pyo a8wobrectocs <br />° RC%V 3912 � p� see RC%V 39.11040(2)(d) <br />dtoaasanl h�dred 402M kr the9e o" sita9 be adapt a to allow ae A%%-4il6.A_eucy to subdivides _y pbUk racks pmjm of more,h h,.o <br />MV 391? 010(1 . <br />0 Aptnwal. Howad ride of ludiviihiel Aedaeri zed to Approve This Form Phose Number Email Address <br />on Betaatfofilm Awaiting Agency(" a per) <br />S'fioat re of todridual Authorized to Approve This Form on lies 2U orlhe Bate — <br />Awarding Agency <br />Received: Department of Labor• & Industties -- ----- --- <br />Date: <br />t'700-106-004 Combined Went &Affidavit-- Small Wot%s—($2,5 1 or less) 09-2010 <br />