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HomeMy WebLinkAbout22 Affidavit of Wages Paid F700-007-000 Affidavit of Wages Paid 06-2014 Department of Labor and Industries Prevailing Wage Program (360) 902-5335 www.Lni.wa.gov/TradesLicensing/PrevWage/default.asp 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 business days for processing. Once approved, your form will be posted online at: https://fortress.wa.gov/lni/wagelookup/searchforms.aspx Affidavit of Wages Paid Public Works Contract $40.00 Filing Fee Required* *Exemption may apply. See instruction 9. Affidavit ID # (Assigned by L&I): # Your Company Information Awarding Agency Information Your Company Name Project Name Contract Number Your Company 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 Was Performed City Where Work Was Performed Additional Details Contract Details Your Job Start Date (mm/dd/yyyy) / / Your Date Work Completed (mm/dd/yyyy) / / Bid Due Date (Prime Contractor’s) Award Date (Prime Contractor’s) Job Site Address/Directions Your Approved Intent ID # Indicate Total Dollar Amount of Your Contract (including sales tax). $ EHB 2805 (RCW 39.04.370) – Is the Prime Contractor’s contract at a cost of over one million dollars ($1,000,000)? No Yes If “Yes” to the EHB 2805 question and the Award Date is 9/1/2010 or later you must complete and submit the EHB 2805 (RCW 39.04.370) Addendum. 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 Hiring Contractor’s Company Name Prime Contractor’s Registration Number Prime Contractor’s UBI Number Hiring Contractor’s Registration Number Hiring Contractor’s UBI Number Employment Information Did you use ANY subcontractors? Yes (Addendum B Required) No Did employees perform work on this project? Yes No Was ALL work subcontracted? Yes (Addendum B Required) No Did you use apprentice employees? Yes No Number of Owner/Operators who own at least 30% of the company who performed work on this project: You must list the First and Last Name(s) of any Owner/Operator performing work below None (0) One (1) Two (2) Three (3) List your Crafts/Trades/Occupations Below - For Journey Level Workers you must provide all of the information below. Owner/Operators - must provide their First and Last name no other information required. **Apprentices are not recorded below. You must use Addendum D to list Apprentices. Number of Workers Total # of Hours Worked 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 on the form and any addenda is correct and that all workers I employed on this Public Works Project were 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 Department of Labor and Industries APPROVED BY: Industrial Statistician