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HomeMy WebLinkAbout28Job #037008 MMIL To, INDUSMIAL -kFATISTICIAN AFFIDAVIT OF Deparlpinent ac of Labor & [ad. WAGES PAID Eniployinew S"umlards DI-W. I General Adodrilatration Baildi, ON PUBIAC WORKS CONT g 4ACT OlYmPia, %VA 98504 MAR (206) 75-1-.-Olg 0110MMKContra Number MY QWF Was Due 1/7/ST7 Contract Awarding Public Agency City Of Renton Date Contract Awarded 1/7/ 7 Date Work Completed 1/20/87 Address County in Which Work Performed King Location Within County Renton Telephone Number Was a Statement of Intent Filed? yes No In compliance with RCW 39.12.040 1, the undersigned, being a duly authorized representative of LAKESIDE INDUSTRIES P. 0. Box 1379; Bellevue, WA 98009 (C--- - sub---) do hereby certify that the following rates of hourly wage and hourly fringe benefits have been paid to the laborers, workmen and mechanics employed by me upon the project described above and that no lalborer.sworkman or mechanic has been paid less than the "prevailing rate of wage" as determined by the Industria Stati tician of the De r-tmcnt of I - I r an Industries. List below each classification of labor employed by you upon the project described above and the rate of hourly pay and hourly fringe bencf-its paid to each classification. Please Note If apprentices have been employed on this project, provide this additional information: name, registration number and stage of progression. C-ft Ho-dy Py FhW B-Wk. Paid SEE ATTACHED N­ Att�ch Additi�] Sb—. .. N-&d. Subscribed and sworn to before me this /Z day of 19 INSTRUCTIONS: CITY OF RENTON, R 2 r E I V F Pursuant to RCW 39.12.040 copies of this form must be completed by the contractor and each of his sub- contractors. 2. Complete this form in triplicate and have it notarized, 3- Submit all forms for approval to: Employment Standards Division, Department of Labor and Industries, General Administration Building, Olympia, Washington 98504. 4. Mail an approved copy to the Contract Awarding Public Agency CONTRACTORS ARE RESPONSIBLE FOR OBTAINING AND FILING AFFIDAVITS of the SUB- CONTRACTORS. This is required by law and payments can not lawfully be made until such affidavits are filed. -WlIW � eo CITY OF RENTON DEC E IV Ef-, MAR 12 1987 �,URCHASING DEPIr. CP LAKESIDE INDUSTRIES y, N—) �77L-J( By " Mary Dodt6n, Contract Ad.ir�