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HomeMy WebLinkAbout21 Statement of Intent to Pay Prevailing WagesNOTICE: If the prime contract is at a cost of over one million dollars ($1,000,000.00), RCW 39.04.370 requires you to complete the EHB 2805 (RCW 39.04.370) Addendum and attach it to your Affidavit of Wages of Paid when your work on the project concludes. This is only a notice. The EHB 2805 Addendum is not submitted with this Intent. F700-029-000 Statement of Intent to Pay Prevailing Wages 03-2011 Your Company Information Awarding Agency Information Your Company Name Project Name Contract Number Your Address Awarding Agency City State Zip+4 Awarding Agency Address Your Contractor Registration Number Your UBI Number City State Zip+4 Your Industrial Insurance Account Number Awarding Agency Contact Name Phone Number Your Email Address (required for notification of approval) Your Phone Number County Where Work Will Be Performed City Where Work Will Be Performed Additional Details Contract Details Your Expected Job Start Date (mm/dd/yyyy) Bid Due Date (Prime Contractor’s) Award Date (Prime Contractor’s) Job Site Address/Directions Total Dollar Amount of Your Contract (including sales tax) or indicate time and materials, if applicable. $ T&M ARRA Funds Weatherization or Energy Efficient Funds Does this project utilize American Recovery and Reinvestment Act (ARRA) funds? Yes No Does this project utilize any weatherization or energy efficiency upgrade funds (ARRA or otherwise)? Yes No Prime Contractor’s Company Information Hiring Contractor’s Company Information Prime Contractor’s Company Name Prime Contractor’s Intent Number Hiring Contractor’s Company Name Prime Contractor’s Registration Number Prime Contractor’s UBI Number Hiring Company’s Contractor Registration Number Hiring Contractors UBI Number Employment Information Do you intend to use ANY subcontractors? Yes No Will employees perform work on this project? Yes No Will ALL work be subcontracted? Yes No Do you intend to use apprentice employees? Yes No Number of Owner/Operators who own at least 30% of the company who will perform work on this project: None (0) One (1) Two (2) Three (3) Crafts/Trades/Occupations – (Do not list apprentices. They are listed on the Affidavit of Wages Paid only.) If an employee works in more than one trade, ensure that all hours worked in each trade are reported below. For additional crafts/trades/occupations please use Addendum A. Number of Workers Rate of Hourly Pay Rate of Hourly Usual (“Fringe”) Benefits Signature Block I hereby certify that I have read and understand the instructions to complete this form and that the information, including any addenda, are correct and that all workers I employ on this Public Works Project will be paid no less than the Prevailing Wage Rate(s) as determined by the Industrial Statistician of the Department of Labor and Industries. Print Name: Print Title: Signature: Date: For L&I Use Only Approved by signature of the Department of Labor and Industries Industrial Statistician • This form must be typed or printed in ink. • Fill in all blanks or the form will be returned for correction (see instructions). • Please allow a minimum of 10 working days for processing. • Once approved, your form will be posted online at https://fortress.wa.gov/lni/pwiapub/SearchFor.asp Department of Labor and Industries Prevailing Wage (360) 902-5335 www.lni.wa.gov/TradesLicensing/PrevWage STATEMENT OF INTENT TO PAY PREVAILING WAGES Public Works Contract $40.00 Filing Fee Required Intent ID # (Assigned by L&I)_______________