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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�