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Home My WebLink AboutWTR2703604_6AGENDA BILL SCHEDULE AGENDA BILL TITLE F;� �c`y �5�� w�o� — SE S Ch S� � tour PREPARED BY: LL)_L& l (Extension: '7 D DEADLINE/DATE ACTION t6 �ae 13 GREGG'S SIGNATURE ��Lalao13 TRANSMIT TO CLERK VIA Electronic Agenda Bill Process COUNCIL MEETING DATE Referred to Committee COMMITTEE MEETING DATE (e-mail Committee Report to Teresa who will final it and send it up to Julia) COMMITTEE Time: Place: COUNCIL MEETING REPORTED OUT USA\17\Misc Forms\AB-Schedule\tp CITY OF RENTON COUNCIL AGENDA BILL Al #: Submitting Data: Public Works For Agenda of: Dept/Div/Board.. Utility Systems/Water Utility January 28, 2013 Agenda Status Staff Contact....... Andrew Weygandt, x7208 Consent ................ X Public Hearing...... Subject: Final Pay Estimate — CAG-12-056 (WTR-27-3604) Correspondence... SE 5th Street AC Water Main Replacement Project Ordinance............ Resolution............ Old Business......... New Business....... Exhibits: Pay Estimate #4 (Final) Study Sessions...... Notice of Completion of Public Works Contract Information.......... Recommended Action: Approvals: Council Concur Legal Dept.......... Finance Dept...... X Fiscal Impact: Expenditure Required... $3,608.03 (final pay est. only) Transfer/Amendment....... Amount Budgeted........ $3,700.00 (final pay est. only) Revenue Generated......... Total Project Budget..... $500,000.00 (Acct. 425/455170) City Share Total Project.... 100% SUMMARY OF ACTION: On May 14, 2012, Council awarded the construction contract to B&B Utilities and Excavating, LLC. Construction started on July 12, 2012, and the project was completed on September 28, 2012. The original contract amount was $296,821.65 and the final contract amount is $287,359.89. The reduction in contract amount is due to reducing the pavement restoration area from the bid amount shown on the original engineering drawings. The project was completed on schedule and within the amount budgeted. STAFF RECOMMENDATION: Accept the project, approve the final pay estimate in the amount of $3,608.03, and release the retainage bond after 60 days, subject to the receipt of all required authorizations. H:\File Sys\WTR - Drinking Water Utility\WTR-27 - Water Project Files\WTR-27-3604 SE 5th St AC MAin Replace ment\Construction Contract\WTR-27-3604_agenda-bill-final-payme nt.doc/AWa h TO: FINANCE DIRECTOR FROM: PUBLIC WORKS ADMINISTRATOR CONTRACTOR: B&B Utilities and Excavating, LLC CONTRACT NO. CAG-12-056 ESTIMATE NO. 4 (Final) PROJECT: SE 5th Street AC Water Main Replacement Project 1. CONTRACTOR EARNINGS THIS ESTIMATE $3,295.00 2. SALES TAX @ 9.50% $313.03 3. TOTAL CONTRACT AMOUNT THIS ESTIMATE $3,608.03 4. EARNINGS PREVIOUSLY PAID CONTRACTOR $246,177.41 5. * EARNINGS DUE CONTRACTOR THIS ESTIMATE $3,130.25 6. SUBTOTAL - CONTRACTOR PAYMENTS $249,307.66 7. RETAINAGE ON PREVIOUS EARNINGS $12,956.71 8. ** RETAINAGE ON EARNINGS THIS ESTIMATE $164.75 9. SUBTOTAL - RETAINAGE $13,121.46 10. SALES TAX PREVIOUSLY PAID $24,617.74 11. SALES TAX DUE THIS ESTIMATE $313.03 12. SUBTOTAL - SALES TAX $24,930.77 * (95% x LINE 1) ** (RETAINAGE: 5%) GRAND TOTAL: $287,359.89 FINANCE DEPARTMENT ACTION: PAYMENT TO CONTRACTOR (Lines 5 and 11): ACCOUNT # 425.455170.018.595.34.63.000 # 4 $3,443.28 RETAINED AMOUNT (Line 8): ACCOUNT # 425.455170.018.595.34.63.000 # 4 $164.75 TOTAL THIS ESTIMATE: $3,608.03 CHARTER 116, LAWS OF 1965 CITY OF RENTON CERTIFICATION I, THE UNDERSIGNED DO HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT THE MATERIALS HAVE BEEN FURNISHED, THE SERVICES RENDERED OR THE LABOR PERFORMED AS DESCRIBED HEREIN, AND THAT THE CLAIM IS A JUST, DUE AND UNPAID OBLIGATION AGAINST THE CITY OF RENTON, AND THAT I AM AUTHORIZED TO AUTHENTICATE AND CERTIFY TO SAID CLAIM Signed: Ny-�-ot",UL" (� ili .�q�► LE�j Printed On: 01/03/2013 City of Renton Public Works Department Page 1 Printed On: 01/03/2013 City of Renton Public Works Department Page 1 Project: SE 5th Street AC Water Main Replacement Project Contractor: B&B Utilities and Excavating, LLC Item Description No. Contract Number: CAG-12-056 Pay Estimate 4 (Final) Closing Date: 12/28/2012 Unit Est. Unit Previous Previous This Quantity Price Quantity Amount Quantity 001. Mobilization, Demobilization, Site Preparation & Clean-up Lump Sum 1 $20,000.00 002. Traffic Control Lump Sum 1 $3,000.00 003. Trench Excavation Safety Systems Lump Sum 1 $2.000.00 004. Construction Surveying and Staking Lump Sum 1 $2,000.00 As -Built Surveying for Progress Payments and Final As- 005. Builts Lump Sum 1 $200.00 006. Temporary Erosion and Sedimentation Control Lump Sum 1 $450.00 007. Site Specific Potholing Each 10 $50.00 Furnish and Install 8' Cl 52 DI Water Pipe & Fittings w/ 008. Polywrap Lineal Foot 1760 $61.00 009. Furnish and Install 8' Gate Valve Assembly Each 5 $900.00 010. Concrete for Thrust Blocking, Dead -Man Anchor Blocks Cubic Yard 10 $100.00 Furnish and Install 16"x8" Wet -Tap Tee & Gate Valve Ott. Assembly Each 1 $5,000.00 012. Furnish and Install Fire Hydrant Assembly Each 2 $4,000.00 013. Relocate Existing Fire Hydrant Each 1 $2,500.00 014. Furnish & Install 3/4" Water Service Connection Each 35 $1,360.00 015. Connection to Existing Water Main Each 4 $2.500.00 016. Cut, Cap, and Block Existing Water Main Each 2 $1,500.00 Removal and Replacement of Unsuitable Foundation 017. Material Ton 50 $1.00 018. Select Imported Trench Backfill Ton 800 $0.10 019. Crushed Surfacing Top Course and Crushed Rock Backfill Ton 300 $0.10 020. 2" Temporary Cold Mix Asphalt Trench Patching Ton 150 $1.00 021. H.M.A. Class %" PG 64-22 for Roadway Reconstruction Ton 300 $110.00 022. Removal and Replacement of Concrete Curb and Gutter Lineal Foot 200 $22.00 023. Concrete Driveway and/or Sidewalk Restoration Square -Yard 150 $55.00 024. Property & Landscape Restoration Lump Sum 1 $8.000.00 C01 H.M.A. Class %" PG 64-22for Roadway Reconstruction Ton 129 $131.92 Force account work for additional pavement repair and CO2 equipment rental. Lump Sum 1 $4,923.09 Sub -total 9.5 % sales tax TT Total This Total Total Amount Quantity Amour 0.90 $18,000.00 0.10 $2,000.00 1.00 $20,000.00 0.90 $2,700.00 0.10 $300.00 1.00 $3,000.00 1.00 $2,000.00 0.00 $0.00 1.00 $2,000.00 1.00 $2,000.00 0.00 $0.00 1.00 $2,000.00 0.25 $50.00 0.75 $150.00 1.00 $200.00 0.90 $405.00 0.10 $45.00 1.00 $450.00 4.00 $200.00 0.00 $0.00 4.00 $200.00 1721.00 $104,981.00 0.00 $0.00 1721.00 $104,981.00 3.00 $2,700.00 0.00 $0.00 3.00 $2,700.00 3.75 $375.00 0.00 $0.00 3.75 $375.00 1.00 $5,000.00 0.00 $0.00 1.00 $5,000.00 2.00 $8,000.00 0.00 $0.00 2.00 $8,000.00 1.00 $2,500.00 0.00 $0.00 1.00 $2,500.00 46.00 $62,560.00 0.00 $0.00 46.00 $62,560.00 4.00 $10,000.00 0.00 $0.00 4.00 $10,000.00 3.00 $4,500.00 0.00 $0.00 3.00 $4,500.00 0.00 $0.00 0.00 $0.00 0.00 $0.00 38.16 $3.82 0.00 $0.00 38.16 $3.82 196.33 $19.63 0.00 $0.00 196.33 $19.63 12.50 $12.50 0.00 $0.00 12.50 $12.50 0.00 $0.00 0.00 $0.00 0.00 $0.00 58.00 $1,276.00 0.00 $0.00 58.00 $1,276.00 49.28 $2,710.40 0.00 $0.00 49.28 $2,710.40 0.90 $7,200.00 0.10 $800.00 1.00 $8,000.00 129.00 $17,017.68 0.00 $0.00 129.00 $17,017.68 1.00 $4,923.09 0.00 $0.00 1.00 $4,923.09 $259,134.12 $3,295.00 $262,429.12 $24,617.74 $313.03 $24,930.77 $283,751.86 $3,608.03 $287.359.89 NOTICE OF COMPLETION OF PUBLIC WORKS CONTRACT Name & Address of Public Agency City of Renton 1055 S Grady Way Renton, WA 98057 UBI Number: 177000094 Contractor's UBI Number: Date: 602619105 01/29/2013 Department Use Only Assigned to: Date Assigned: Notice is herebv Qiven relative to the completion of contract or project described below Project Name Contract Number Job Order Contracting SE 5th Street AC Water Main Replacement Project CAG-12-056 ❑ Yes 0 No Description of Work Done/include Jobsite Address(es) Work located on SE 5th Street in Renton, WA approximately 350 feet east of Maple Valley Hwy (SR169) and consisted of the installation of 1,720 feet of new 8" ductile iron water main. Federally funded road transportation project? ❑ Yes ❑ No Contractor's Name Telephone Number B&B Utilities and Excavating, LLC 425-398-5906 Contractor Address 23431 45th Ave SE, Bothell, WA 98021 If Retainage is Bonded, List Surety's Name (or attach a copy) Surety Agent's Address Date Contract Awarded Date Work Commenced Date Work Completed Date Work Accepted 05/14/2012 107/12/2012 09/28/2012 110/01/2012 Contract Amount Additions ( + ) Reductions (- ) Sub -Total Amount of Sales Tax Paid at 9.500% (If various rates apply, please send a breakdown) TOTAL Please List all Subcontractors Below: $ 271,070.00 $ 24,359.12 Liquidated Damages $ $ 33,000.00 Amount Disbursed $ $ 262,429.12 Amount Retained $ $ 24,930.77 $ 287,359.89 TOTAL $ NOTE: These two totals must be equal 274,238.43 13,121.46 287,359.89 Subcontractor's Name: UBI Number: Affidavit ID (if known) Salinas Sawing and Sealing, Inc. 601717158 427262 Northshore Paving, Inc. 600635278 Concrete Services, Inc. 601334103 F215-038-000 08-2011 REV 31 0020e (08/25/11) Continued on page 2 Please List all Subcontractors Below: Subcontractor's Name: I UBI Number: I Affidavit ID (if known) Comments Contact Name: Natalie Wissbrod Title: Accounting Assistant Email Address: nwissbrod@rentonwa.gov Phone Number: 425-430-6919 o e: I ne uisnursing unicer must sunmit mis compictea notice imme to e y a er acceptance oT me worK cone uncier mis con rac . NO PAYMENT SHALL BE MADE FROM RETAINED FUNDS until receipt of all release certificates. Submitting Form: Please submit the completed form to all three agencies below. For a faster response, please submit by e-mail. Washington State Washington State .Arlr Washington State Department of Revenue Department of Labor and Industries f Employment Security Department Public Works Section Contract Release Specialized Collections Unit PO Box 47474 PO Box 44274 PO Box 9046 Olympia WA 98504-7474 Olympia, WA 98504-4272 Olympia WA 98507-9046 (360)725-7588 (360)902-4754 (360) 902-9780 FAX (360) 664-4159 FAX (360) 902-6897 Fax (360) 902-9287 PWC@dor.wa.gov ContractRelease@lni.wa.gov publicworks@esd.wa.gov For tax assistance or to request this document in an alternate format, visit http://dor.wa.gov or call 1-800-647-7706. Teletype (TTY) users may call (360) 705-6718. F215-038-000 08-2011 REV 31 0020e (8/25/11) rnniri �pQc►.ir^� Submitting Data: Public Works For Agend Dept/Div/Board.. Utility Systems/Water Utility January 28, 2013 Agenda Status Staff Contact....... Andrew Weygandt, x7208 Consent ................ X Public Hearing...... Subject: Final Pay Estimate — CAG-12-056 (WTR-27-3604) Correspondence... SE 5th Street AC Water Main Replacement Project Ordinance............ Resolution............ Old Business......... New Business....... Exhibits: Pay Estimate #4 (Final) Study Sessions...... Notice of Completion of Public Works Contract Information.......... Recommended Action: Approvals: Council Concur Legal Dept.......... Finance Dept...... X Fiscal Impact: Expenditure Required... $3,608.03 (final pay est. only) Transfer/Amendment....... Amount Budgeted........ $3,700.00 (final pay est. only) Revenue Generated......... Total Project Budget..... $500,000.00 (Acct. 425/455170) City Share Total Project.... 100% SUMMARY OF ACTION: On May 14, 2012, Council awarded the construction contract to B&B Utilities and Excavating, LLC. Construction started on July 12, 2012, and the project was completed on September 28, 2012. The original contract amount was $296,821.65 and the final contract amount is $287,359.89. The reduction in contract amount is due to reducing the pavement restoration area from the bid amount shown on the original engineering drawings. The project was completed on schedule and within the amount budgeted. STAFF RECOMMENDATION: Accept the project, approve the final pay estimate in the amount of $3,608.03, and release the retainage bond after 60 days, subject to the receipt of all required authorizations. H:\File Sys\WTR - Drinking Water Utility\WTR-27 - Water Project Files\WTR-27-3604 SE 5th St AC MAin Replacement\Construction Contract\WTR-27-3604_agenda-bill-final-payment.doc/AWa h PUBLIC WORKS DEPARTMENT Cit of tffi n y M E M O R A N D U M DATE: January 31, 2013 TO: Natalie Wissbrod, Finance Accounting Assistant FROM: Andrew Weygandt, Water Utility Engineer, x7208k SUBJECT: SE Sth Street AC Water Main Replacement Project (CAG-12-056) — Final Pay Estimate At its meeting of January 28, 2013, the Renton City Council accepted the construction project, SE 5th Street AC Water Main Replacement Project, and approved the final payment estimate and release of retainage for B&B Utilities and Excavating, LLC. Attached please find the following documents: • Notice of Completion of Public Works Contract for CAG-12-056 • Original of Final Pay Estimate for CAG-12-056 • Statement of Intent to Pay Prevailing Wages, Affidavit of Wages Paid for: ■ B&B Utilities and Excavating, LLC (prime contractor) ■ Northshore Paving, Inc. (subcontractor) ■ Salinas Sawing and Sealing, Inc. (subcontractor) Please process the final pay estimate and begin the process to release retainage for this construction contract. Thank You. Attachments h:\file sys\wtr - drinking water utility\wtr-27 - water project files\wtr-27-3604 se 5th st ac main replacement\construction contract\3604-finalpayestimatememo.doc\AWah TO: ' I FINANCE DIRECTOR FROM: PUBLIC WORKS ADMINISTRATOR CONTRACTOR: B&B Utilities and Excavating, LLC CONTRACT NO. CAG-12-056 PROJECT: SE 5th Street AC Water Main Replacement Project 1. CONTRACTOR EARNINGS THIS ESTIMATE 2. SALES TAX @ 9.50% 3. TOTAL CONTRACT AMOUNT THIS ESTIMATE ESTIMATE NO. 4 (Final) $3,295.00 $313.03 4. EARNINGS PREVIOUSLY PAID CONTRACTOR $246,177.41 5. ' EARNINGS DUE CONTRACTOR THIS ESTIMATE $3,130.25 6. SUBTOTAL - CONTRACTOR PAYMENTS 7. RETAINAGE ON PREVIOUS EARNINGS $12,956.71 8. ** RETAINAGE ON EARNINGS THIS ESTIMATE $164.75 9. SUBTOTAL - RETAINAGE $3,608.03 $249,307.66 $13,121.46 10. SALES TAX PREVIOUSLY PAID $24,617.74 11. SALES TAX DUE THIS ESTIMATE $313.03 12. SUBTOTAL - SALES TAX $24,930.77 * (95% x LINE 1) " (RETAINAGE: 5%) GRAND TOTAL: $287,359.89 FINANCE DEPARTMENT ACTION: PAYMENT TO CONTRACTOR (Lines 5 and 11): ACCOUNT # 425.455170.018.595.34.63.000 # 4 $3,443.28 RETAINED AMOUNT (Line 8): ACCOUNT # 425.455170.018.595.34.63.000 # 4 $164.75 TOTAL THIS ESTIMATE: $3,608.03 CHARTER 116, LAWS OF 1965 CITY OF RENTON CERTIFICATION I, THE UNDERSIGNED DO HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT THE MATERIALS HAVE BEEN FURNISHED, THE SERVICES RENDERED OR THE LABOR PERFORMED AS DESCRIBED HEREIN, AND THAT THE CLAIM IS A JUST, DUE AND UNPAID OBLIGATION AGAINST THE CITY OF RENTON, AND THAT I AM AUTHORIZED TO AUTHENTICATE AND CERTIFY TO SAID CLAIM Signed: kotuv C AhLl 13 /- 11''1z'3 Printed On: 01/03/2013 City of Renton Public Works Department Page 1 Printed On: 01/03/2013 City of Renton Public Works Department Page 1 Project: SE 5th Street AC Water Main Replacement Project Contractor: B&B Utilities and Excavating, LLC Item Description No. Contract Number: CAG-12-056 Pay Estimate 4 (Final) Closing Date: 12/28/2012 Unit Est. Unit Previous Previous This Quantity Price Quantity Amount Quantity This Total Total 001. Mobilization, Demobilization, Site Preparation & Clean-up Lump Sum 1 $20,000.00 0.90 $18,000.00 0.10 $2,000.00 1.00 $20,000.00 002. Traffic Control Lump Sum 1 $3,000.00 0.90 $2,700.00 0.10 $300.00 1.00 $3,000.00 003. Trench Excavation Safety Systems Lump Sum 1 $2,000.00 1.00 $2,000.00 0.00 $0.00 1.00 $2,000.00 004. Construction Surveying and Staking Lump Sum 1 $2,000,00 1.00 $2,000.00 0.00 $0.00 1.00 $2,000.00 As -Built Surveying for Progress Payments and Final As- 005. Builts Lump Sum 1 $200.00 0.25 $50.00 0.75 $150.00 1.00 $200.00 006. Temporary Erosion and Sedimentation Control Lump Sum 1 $450.00 0.90 $405.00 0.10 $45.00 1.00 $450.00 007. Site Specific Potholing Each 10 $50.00 4.00 $200.00 0.00 $0.00 4.00 $200.00 Furnish and Install 8" Cl 52 DI Water Pipe & Fittings w/ 008. Polywrap Lineal Foot 1760 $61.00 1721.00 $104,981.00 0.00 $0.00 1721.00 $104,981.00 009. Furnish and Install 8" Gate Valve Assembly Each 5 $900.00 3.00 $2,700.00 0.00 $0.00 3.00 $2.700.00 010. Concrete for Thrust Blocking, Dead -Man Anchor Blocks Cubic Yard 10 $100.00 3.75 $375.00 0.00 $0.00 3.75 $375.00 Furnish and Install 16"x8" Wet -Tap Tee & Gate Valve 011. Assembly Each 1 $5,000.00 1.00 $5,000.00 0.00 $0.00 1.00 $5,000.00 012. Furnish and Install Fire Hydrant Assembly Each 2 $4,000.00 2.00 $8,000.00 0.00 $0.00 2.00 $8.000.00 013. Relocate Existing Fire Hydrant Each 1 $2,500.00 1.00 $2.500.00 0.00 $0.00 1.00 $2,500.00 014. Furnish & Install 3/4" Water Service Connection Each 35 $1.360.00 46.00 $62.560.00 0.00 $0.00 46.00 $62,560.00 015. Connection to Existing Water Main Each 4 $2,500.00 4.00 $10.000.00 0.00 $0.00 4.00 $10,000.00 016. Cut. Cap, and Block Existing Water Main Each 2 $1,500.00 3.00 $4.500.00 0.00 $0.00 3.00 $4,500.00 Removal and Replacement of Unsuitable Foundation 017. Material Ton 50 $1.00 0.00 $0.00 0.00 $0.00 0.00 $0.00 018. Select Imported Trench Backfll Ton 800 $0.10 38.16 $3.82 0.00 $0.00 38.16 $3.82 019, Crushed Surfacing Top Course and Crushed Rock Backfll Ton 300 $0.10 196.33 $19.63 0.00 $0.00 196.33 $19.63 020. 2" Temporary Cold Mix Asphalt Trench Patching Ton 150 $1.00 12.50 $12.50 0.00 $0.00 12.50 $12.50 021. H.M.A. Class Y2' PG 64-22 for Roadway Reconstruction Ton 300 $110.00 0.00 $0.00 0.00 $0.00 0.00 $0.00 022. Removal and Replacement of Concrete Curb and Gutter Lineal Foot 200 $22.00 58.00 $1,276.00 0.00 $0.00 58.00 $1,276.00 023. Concrete Driveway and/or Sidewalk Restoration Square -Yard 150 $55.00 49.28 $2,710.40 0.00 $0.00 49.28 $2,710.40 024. Property & Landscape Restoration Lump Sum 1 $8,000.00 0.90 $7,200.00 0.10 $800.00 1.00 $8,000.00 C01 H.M.A. Class Y/' PG 64-22 for Roadway Reconstruction Ton 129 $131.92 129.00 $17,017.68 0.00 $0.00 129.00 $17,017.68 Force account work for additional pavement repair and CO2 equipment rental. Lump Sum 1 $4,923.09 1.00 $4,923.09 0.00 $0.00 1.00 $4,923.09 Sub -total $259,134.12 $3,295.00 $262,429.12 9.5 % sales tax $24,617.74 $313.03 $24,930.77 TT Total $283,751.86 $3,608.03 $287,359.89 v TO: FINANCE DIRECTOR FROM: PUBLIC WORKS ADMINISTRATOR CONTRACTOR: B&B Utilities and Excavating, LLC CONTRACT NO. # CAG-12-056 COPY ESTIMATE NO. 1 PROJECT: SE 5th Street AC Water Main Replacement Project 1. CONTRACTOR EARNINGS THIS ESTIMATE $208,411.95 2. SALES TAX @ 9.50% $19,799.14 3. TOTAL CONTRACT AMOUNT THIS ESTIMATE $228,211.09 4. EARNINGS PREVIOUSLY PAID CONTRACTOR $0.00 5. ' EARNINGS DUE CONTRACTOR THIS ESTIMATE $197,991.35 6. SUBTOTAL - CONTRACTOR PAYMENTS $197,991.35 7. RETAINAGE ON PREVIOUS EARNINGS 8. *' RETAINAGE ON EARNINGS THIS ESTIMATE 9. SUBTOTAL - RETAINAGE 10. SALES TAX PREVIOUSLY PAID 11. SALES TAX DUE THIS ESTIMATE 12. SUBTOTAL - SALES TAX (95% x LINE 1) " (RETAINAGE: 5%) FINANCE DEPARTMENT ACTION: PAYMENT TO CONTRACTOR (Lines 5 and 11): ACCOUNT # 425.455170.018.595.34.63.000 RETAINED AMOUNT (Line 8): ACCOUNT # 425.455170.018.595.34.63.000 CHARTER 116, LAWS OF 1965 CITY OF RENTON CERTIFICATION $0.00 $10,420.60 $0.00 $19,799.14 GRAND TOTAL TOTAL THIS ESTIMATE $10,420.60 $19,799.14 $228,211.09 # 1 $217,790.49 # 1 $10,420.60 $228,211.09 I THE UNDERSGNED DO HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT THE MATERIALS HAVE BEEN FURNISHED. THE SERVICES RENDERED OR THE LABOR PERFORMED AS DESCR',BED HEREIN, AND THAT THE CLAIM IS A JUST. DUE AND UNPAID OBLIGATION AGAINST THE CITY OF RENTON AND THAT I AM AUTHORIZED TO AUTHENTICATE[WD CERTIFY TO S40�1 LA!M Signed: NOW./ huatu� Z7) 7012 Printed On: 08/27i2012 City of Renton Public Works Department Page 1 Printed On: 08/27/2012 Project: SE 5th Street AC Water Main Replacement Project Contractor: B&B Utilities and Excavating, LLC Item Description No. City of Renton Public Works Department Contract Number. Pay Estimate 1 Closing Date: Unit Est Unit Previous Previous Quantity Price _ Quantity _ Amount Page 1 This This Total Total 001. Mobilization, Demobilization, Site Preparation 8 Clean-up Lump Sum 1 $20,000.00 $0.00 0.50 $10.000.00 050 $10,000.00 002 Traffic Control Lump Sum 1 $3.000 00 $0.00 0.60 $1,800.00 060 $1,800.00 003 Trench Excavation Safety Systems Lump Sum 1 $2.000.00 $0.00 0.75 $1,500.00 0.75 $1.500.00 004. Construction Surveying and Staking Lump Sum 1 $2.000.00 $0.00 1,00 $2.00000 1.00 $2,000.00 As -Built Surveying for Progress Payments and Final As- 005 Buills Lump Sum 1 $200 00 $D.00 0-25 $50.00 025 $50.00 006 Temporary Erosion and Sedimentation Control Lump Sum 1 $450 00 $0.00 0.60 $270.00 060 $270.00 007. Site Specific Potholing Each 10 $50 00 $0.00 4.00 $200 00 4.00 $200.00 Furnish and Install B' Cl 52 DI Water Pipe 8 Fittings w/ 008. Polywrap Lineal Foot 1760 $61 00 $0.00 1721.00 $104,981.00 1721.D0 $104,981.00 009. Furnish and Install 8' Gate Valve Assembly Each 5 $900 00 $0.00 300 $2,700.00 3.00 $2.700.00 010. Concrete for Thrust Blocking, Dead -Man Anchor Blocks Cubic Yard 10 5100.00 $0.00 1.75 $175.00 1.75 $175.00 Furnish and Install i6'x8' Wet -Tap Tee & Gate Valve 011. Assembly Each 1 $5,000 00 50.00 too $5.000 00 1.00 $5,000.00 012 Furnish and Install Fire Hydrant Assembly Each 2 $4.000.00 $0.00 Zoo $8,000 00 2.00 $8,000.00 013, Relocate Existing Fire Hydrant Each 1 $2,500.00 $0.00 100 $2.500.00 1.00 $2,500.00 014. Furnish 8 Install 3/4' Water Service Connection Each 35 $1,360.00 $0.00 4500 $61.200.00 45.00 $61,200.00 015. Connection to Existing Water Main Each 4 $2,500.00 $0.00 2.00 $5,D00.00 2.00 $5,000.00 ' 016. Cut, Cap, and Block Existing Water Main Each 2 $1,500.00 $0.00 200 $3,000.00 2.00 $3,000.00 Removal and Replacement of Unsuitable Foundation 017. Material Ton 50 $1.00 $0.00 0.00 $0.00 0.00 $0.00 018. Select Imported Trench Backfill Ton 800 $0.10 50.00 38.16 $3.82 3B 16 $3.82 019. Crushed Surfacing Top Course and Crushed Rock Backfill Ton 300 $0.10 $0.00 196.33 $19 63 196.33 $19.63 020. 2" Temporary Cold Mix Asphalt Trench Patching Ton 150 $1.00 $0.00 12.50 $12.50 1250 $12,50 H.M.A. Class %' PG 64.22 for Roadway Reconstruction 021. including Crushed Surfacing Top Course Ton 300 $110.00 $0.00 000 $0.00 0.00 $0.00 022, Removal and Replacement of Concrete Curb and Gutter Lineal Foot 200 $22.00 $0.00 0.00 $0 00 0.00 $0.00 023. Concrete Driveway and/or Sidewalk Restoration Square -Yard 150 $55.00 $0.00 000 $0,00 0.00 $0.00 024. Property & Landscape Restoration Lump Sum 1 $8,000.00 $0 00 000 $0 00 0.00 $0.00 Sub -total 50.00 $208.411.95 $208,411.95 9.5%sales tax $0.00 519,79914 $19,799-14 TT Total $0.00 $228,211.09 $228,211.09 iM0 s�z�/r2 TO: FINANCE DIRECTOR FROM: PUBLIC WORKS ADMINISTRATOR COPY CONTRACTOR: B&B Utilities and Excavating, LLC CONTRACT NO. # CAG-12-056 ESTIMATE NO. 2 PROJECT: SE 5th Street AC Water Main Replacement Project 1. CONTRACTOR EARNINGS THIS ESTIMATE $10,190.00 2. SALES TAX @ 9.50% $968.05 3. TOTAL CONTRACT AMOUNT THIS ESTIMATE $11,158.05 4. EARNINGS PREVIOUSLY PAID CONTRACTOR $197,991.35 5. * EARNINGS DUE CONTRACTOR THIS ESTIMATE $9,680.50 6. SUBTOTAL - CONTRACTOR PAYMENTS 7. RETAINAGE ON PREVIOUS EARNINGS $10,420.60 8. ** RETAINAGE ON EARNINGS THIS ESTIMATE $509.50 9. SUBTOTAL - RETAINAGE 10. SALES TAX PREVIOUSLY PAID $19,799.14 11. SALES TAX DUE THIS ESTIMATE $968.05 12. SUBTOTAL - SALES TAX * (95% x LINE 1) ** (RETAINAGE: 55/6) GRAND TOTAL: FINANCE DEPARTMENT ACTION: PAYMENT TO CONTRACTOR (Lines 5 and 11): ACCOUNT # 425.455170.018.595.34.63.000 # 2 RETAINED AMOUNT (Line 8): ACCOUNT # 425.455170.018.595.34.63.000 # 2 TOTAL THIS ESTIMATE: CHARTER 116, LAWS OF 1965 CITY OF RENTON CERTIFICATION I, THE UNDERSIGNED DO HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT THE MATERIALS HAVE BEEN FURNISHED, THE SERVICES RENDERED OR THE LABOR PERFORMED AS DESCRIBED HEREIN, AND THAT THE CLAIM IS A JUST, DUE AND UNPAID OBLIGATION AGAINST THE CITY OF RENTON, AND THAT I AM / AUTHORIZED TO AUTHENTICATE AND CERTIFY TO SAID CLAIM. / Signed: � $207,671.85 $10,930.10 $20,767.19 $239,369.14 $10,648.55 $509.50 $11,158.05 Printed On: 09/11/2012 City of Renton Public Works Department Paoe 1 +`Printed On: 09/11/2012 Project: SE 5th Street AC Water Main Replacement Project Contractor. B&B Utilities and Excavating, LLC Item Description No. City of Renton Public Works Department Contract Number: Pay Estimate 2 Closing Date: Unit Est. Unit Previous Previous Quantity_ Price _ Quantity Amount Page 1 This This Total Total uantitv Amount Quantitv Amount 001. Mobilization, Demobilization, Site Preparation & Clean-up Lump Sum 1 $20,000.00 0.50 $10,000.00 0.00 $0.00 0.50 $10,000.00 002. Traffic Control Lump Sum 1 $3,000.00 0.60 $1,800.00 0.20 $600.00 0.80 $2,400.00 003. Trench Excavation Safety Systems Lump Sum 1 $2,000.00 0.75 $1,500.00 0.25 $500.00 1.00 $2,000.00 004. Construction Surveying and Staking Lump Sum 1 $2,000.00 1.00 $2,000.00 0.00 $0.00 1.00 $2,000.00 As -Built Surveying for Progress Payments and Final As- 005. Builts Lump Sum 1 $200.00 0.25 $50.00 0.00 $0.00 0.25 $50.00 006. Temporary Erosion and Sedimentation Control Lump Sum 1 $450.00 0.60 $270.00 0.20 $90.00 0.80 $360.00 007. Site Specific Potholing Each 10 $50.00 4.00 $200.00 0.00 $0.00 4.00 $200.00 Furnish and Install 8' Cl 52 DI Water Pipe & Fittings w/ 008. Polywrap Lineal Foot 1760 $61.00 1721.00 $104.981.00 0.00 $0.00 1721.00 $104,981.00 009. Furnish and Install 8" Gate Valve Assembly Each 5 $900.00 3.00 $2,700.00 0.00 $0.00 3.00 $2,700.00 010. Concrete for Thrust Blocking, Dead -Man Anchor Blocks Cubic Yard 10 $100.00 1.75 $175.00 0.00 $0.00 1.75 $175.00 Furnish and Install 16"x8" Wet -Tap Tee & Gale Valve 011. Assembly Each 1 $5,000.00 1.00 $5,000.00 0.00 $0.00 1.00 $5,000.00 012. Furnish and Install Fire Hydrant Assembly Each 2 $4.000.00 2.00 $8.000.00 0.00 $0.00 2.00 $8.000.00 013. Relocate Existing Fire Hydrant Each 1 $2.500.00 1.00 $2.500.00 0.00 $0.00 1.00 $2,500.00 014. Furnish & Install 3/4" Water Service Connection Each 35 $1,360.00 45.00 $61,200.00 0.00 $0.00 45.00 $61.200.00 015. Connection to Existing Water Main Each 4 $2,500.00 2.00 $5,000.00 2.00 $5,000.00 4.00 $10.000.00 016. Cut, Cap, and Block Existing Water Main Each 2 $1.500.00 2.00 $3,000.00 0.00 $0.00 2.00 $3,000.00 Removal and Replacement of Unsuitable Foundation 017. Material Ton 50 $1.00 0.00 $0.00 0.00 $0.00 0.00 $0.00 018. Select Imported Trench Backfill Ton 800 $0.10 38.16 $3.82 0.00 $0.00 38.16 $3.82 019. Crushed Surfacing Top Course and Crushed Rock Backfill Ton 300 $0.10 196.33 $19.63 0.00 $0.00 196.33 $19,63 020. 2" Temporary Cold Mix Asphalt Trench Patching Ton 150 $1.00 12.50 $12.50 0.00 $0.00 12.50 $12.50 H.M.A. Class Y." PG 64-22 for Roadway Reconstruction 021. including Crushed Surfacing Top Course Ton 300 $110.00 0.00 $0.00 0.00 $0.00 0.00 $0.00 022. Removal and Replacement of Concrete Curb and Gutter Lineal Foot 200 $22.00 0.00 $0.00 0.00 $0.00 0.00 $0.00 023. Concrete Driveway and/or Sidewalk Restoration Square -Yard 150 $55.00 0.00 $0.00 0.00 $0.00 0.00 $0.00 024. Property & Landscape Restoration Lump Sum 1 $8,000.00 0.00 $0.00 0.50 $4.000.00 0.50 $4.000.00 Sub -total $208,411.95 $10,190.00 $218,601.95 9.5% sales tax $19,799.14 $968.05 $20,767.19 TT Total $228.211.09 $11,158.05 $239,369.14 9/r/�z TO:` FINANCE DIRECTOR FROM: PUBLIC WORKS ADMINISTRATOR CONTRACTOR: B&B Utilities and Excavating, LLC CONTRACT NO. # CAG-12-056 ESTIMATE NO. 3 CUi-, 'r u PROJECT: SE 5th Street AC Water Main Replacement Project 1. CONTRACTOR EARNINGS THIS ESTIMATE $40,532.17 2. SALES TAX @ 9.50% $3,850.56 3. TOTAL CONTRACT AMOUNT THIS ESTIMATE $44,382.73 4. EARNINGS PREVIOUSLY PAID CONTRACTOR $207,671.85 5. * EARNINGS DUE CONTRACTOR THIS ESTIMATE $38,505.56 6. SUBTOTAL - CONTRACTOR PAYMENTS $246,177.41 7. RETAINAGE ON PREVIOUS EARNINGS $10,930.10 8. ** RETAINAGE ON EARNINGS THIS ESTIMATE $2,026.61 9. SUBTOTAL - RETAINAGE $12,956.71 10. SALES TAX PREVIOUSLY PAID $20,767.19 11. SALES TAX DUE THIS ESTIMATE $3,850.56 12. SUBTOTAL - SALES TAX $24,617.74 * (95% x LINE 1) ** (RETAINAGE: 5%) GRAND TOTAL: $283,751.86 FINANCE DEPARTMENT ACTION: PAYMENT TO CONTRACTOR (Lines 5 and 11): ACCOUNT # 425.455170.018.595.34.63.000 # 3 $42,356.12 RETAINED AMOUNT (Line 8): ACCOUNT # 425.455170.018.595.34.63.000 # 3 $2,026.61 TOTAL THIS ESTIMATE: $44,382.73 CHARTER 116, LAWS OF 1965 CITY OF RENTON CERTIFICATION I, THE UNDERSIGNED DO HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT THE MATERIALS HAVE BEEN FURNISHED, THE SERVICES RENDERED OR THE LABOR PERFORMED AS DESCRIBE6 / HEREIN, AND THAT THE CLAIM IS A JUST, DUE AND UNPAID , z OBLIGATION AGAINST THE CITY OF RENTON, AND THAT I,AM AUTHORIZED TO AUTHENTICATE AND CERTIFY TO SAID CLAIM Signed: j'/V11 v"i. 1 `1 1 2d \2 /0�/ 9/iv / 2- Printed On: 10/19/2012 City of Renton Public Works Department Page 1 r Printed On: 10/19/2012 Project: SE 5th Street AC Water Main Replacement Project Contractor: B&B Utilities and Excavating, LLC Item Description No. City of Renton Public Works Department Contract Number: Pay Estimate 3 Closing Date: Unit Est. Unit Previous Previous 001. Mobilization, Demobilization, Site Preparation & Clean-up Lump Sum 1 $20,000.00 002. Traffic Control Lump Sum 1 $3,000.00 003. Trench Excavation Safety Systems Lump Sum 1 $2,000.00 004. Construction Surveying and Staking Lump Sum 1 $2.000.00 As -Built Surveying for Progress Payments and Final As- 005. Builts Lump Sum 1 $200.00 006. Temporary Erosion and Sedimentation Control Lump Sum 1 $450.00 007. Site Specific Potholing Each 10 $50.00 Furnish and Install 8' Cl 52 DI Water Pipe & Fittings w/ 008. Polywrap Lineal Foot 1760 $61.00 009. Furnish and Install 8' Gate Valve Assembly Each 5 $900.00 010. Concrete for Thrust Blocking, Dead -Man Anchor Blocks Cubic Yard 10 $100.00 Furnish and Install 16'x8" Wet -Tap Tee & Gate Valve 011. Assembly Each 1 $5.000.00 012. Furnish and Install Fire Hydrant Assembly Each 2 $4,000.00 013. Relocate Existing Fire Hydrant Each 1 $2,500.00 014. Furnish & Install 3/4" Water Service Connection Each 35 $1.360.00 015. Connection to Existing Water Main Each 4 $2,500.00 016. Cut, Cap, and Block Existing Water Main Each 2 $1,500.00 Removal and Replacement of Unsuitable Foundation 017. Material Ton 50 $1.00 018. Select Imported Trench Backfill Ton 800 $0.10 019. Crushed Surfacing Top Course and Crushed Rock Backfill Ton 300 $0.10 020. 2" Temporary Cold Mix Asphalt Trench Patching Ton 150 $1.00 021. H.M.A. Class %' PG 64-22 for Roadway Reconstruction Ton 300 $110.00 022. Removal and Replacement of Concrete Curb and Gutter Lineal Foot 200 $22.00 023. Concrete Driveway and/or Sidewalk Restoration Square -Yard 150 $55.00 024. Property & Landscape Restoration Lump Sum 1 $8,000.00 Cot H.M.A. Class %" PG 64-22 for Roadway Reconstruction Ton 129 $131.92 Force account work for additional pavement repair and CO2 equipment rental. Lump Sum 1 $4,923.09 Sub -total 9.5% sales tax TT Total Page 1 This This Total Total 0.50 $10,000.00 0.40 $8,000.00 0.90 $18,000.00 0.80 $2.400.00 0.10 $300.00 0.90 $2,700.00 1.00 $2,000.00 0.00 $0.00 1.00 $2,000.00 1.00 $2,000.00 0.00 $0.00 1.00 $2.000.00 0.25 $50.00 0.00 $0.00 0.25 $50.00 0.80 $360.00 0.10 $45.00 0.90 $405.00 4.00 $200.00 0.00 $0.00 4.00 $200.00 1721.00 $104,981.00 0.00 $0.00 1721.00 $104,981.00 3.00 $2,700.00 0.00 $0.00 3.00 $2.700.00 1.75 $175.00 2.00 $200.00 3.75 $375.00 1.00 $5.000.00 0.00 $0.00 1.00 $5.000.00 2.00 $8,000.00 0.00 $0.00 2.00 $8,000.00 1.00 $2.500.00 0.00 $0.00 1.00 $2.500.00 45.00 $61,200.00 1.00 $1,360.00 46.00 $62,560.00 4.00 $10,000.00 0.00 $0.00 4.00 $10,000.00 2.00 $3,000.00 1.00 $1.500.00 3.00 $4,500.00 0.00 $0.00 0.00 $0.00 0.00 $0.00 38.16 $3.82 0.00 $0.00 38.16 $3.82 196.33 $19.63 0.00 $0.00 196.33 $19.63 12.50 $12.50 0.00 $0.00 12.50 $12.50 0.00 $0.00 0.00 $0.00 0.00 $0.00 0.00 $0.00 58.00 $1,275.00 58.00 $1,276.00 0,00 $0.00 4928 $2,710 40 4928 $2,710.40 0.50 $4,000.00 0.40 $3,200.00 0.90 $7,200.00 0.00 $0.00 129.00 $17,017.68 129.00 $17,017.68 0.00 $0.00 1.00 $4,923.0,9 1.00 $4,923.09 $218,601.95 $40,532.17 $259,134.12 $20,767.19 $3,850.56 $24.617.74 $239,369.14 $44.382.73 $283,751.86 • nit ELT .f 9' ��; n A AJLS - City Clerk Checklist Select One: ❑X Contract ❑ Permit ❑ Lease Staff Name: Andrew Weygandt Extension: Department/Division: Public Works -Water Utility Addendum Number: 1 to City Clerk Number: Contract Class: ❑ Receivable ❑X Payable ❑ Grant Contractor Name: B&B Utilities and Excavating, LLC City Clerk Number CAG-12-056 ❑ Agreement Contract Type (assigned by City Clerk) x7208 EDEN Approval Queue: 05-007P CAG-12-056 (if applicable). ❑ Misc. (no $) Expiration Date: Short Description: SE 5th Street AC Water Main Replacement Project Full or Additional Description: Change Order 1. New unit price for paving based on reduced quantity. ❑ Legal Review (attach memorandum from City Attorney) ❑ Risk Management review for insurance (attach memorandum from Risk Management) ❑ Insurance certificate and/or policy (attach original) ❑ Response to legal or Risk Management concerns (explain, in writing, how concerns have been met) ❑ Performance bond and verification memo from staff (for Public Works contracts only) ❑ Federal excluded parties list verification (Website: www.ep/s.gov, attach printout of search results) ❑ City business license number: BL.032377 Check EDEN or ask Finance Department. ❑ Accounts payable W-9 vendor form (obtain if not already on file with Finance Dept.) Submitted contracts are signed by contractor: ❑X Yes ❑ No If not, provide explanation below. Fiscal Impact: ❑X Expenditure or ❑ Revenue Amount. Budgeted: Amount: $ 17 n1 7 FR (line item; see below*): $ Prior Council approval via agenda bill process required if: (see policies 250-02 and 800-12) ❑ Contract or addendum is $20,000 or over (non -Public Works) or $30,000 or over (Public Works). ❑ " Contract expenditure amount exceeds budgeted amount; fund transfer needed. ❑ Addendum is for the second and additional time extensions. ❑ Interlocal Agreement (most Interlocal Agreements require Resolutions) Date of Council Approval: Resolution Number: (if applicable) (if applicable) O5/1 412012 Cey words for City Clerk's electronic card tile: 3E 5th Street, Maplewood 06/30/14 Contractor determined via: ❑ Phone Bid/Written Quote ❑X CFB Ad ❑ Consultant Roster RFP/SOQ Ad ❑ Application ❑ Sole Source Print Form Revised 07/23/2008 CITY OF RENTON Public Works Department CONTRACT CHANGE ORDER AGREEMENT CONTRACT: CAG 12-056 — SE 51h Street AC Water Main Replacement Project C.O.# 1 CONTRACTOR: B&B Utilities and Excavating, LLC SUMMARY OF PROPOSED CHANGE: Provide all labor, equipment, subcontracting, bonding, insurance for the complete work required for the extra work as outlined below: ITEM Additional Quantities Under This Change Order Unit Quantity Unit Total Price C01 New unit price for paving based on reduced quantity. REMOVE Bid item 21—%" PG 64-22 HMA Ton 300-$110.00 (-$33,000.00) Add Change Order 1—%" PG 64-22 HMA Ton 129 $131.92 $17,017.68 Subtotal (-515,982.32) 9.5% Sales Tax (-$1,518.32) Total (-$17,500.64) ORIGINAL CONTRACT AMOUNT CURRENT CONTRACT AMOUNT ESTIMATED NET CHANGE THIS ORDER ESTIMATED CONTRACT TOTAL AFTER CHANGE $296,821.65 $296,821.65 (-$17,500.64) $279,321.01 Cost Allocation Water Utility 425.455596.018.595.34.63.000 $17,017.68 SIGNATUDEC. Contractor: Project Engir Approved By Date: Date: /v / 9 %Z Date: f� C:\UserslMaulitta\AppData\Local\Nficrosoft\Windows\Temporary Intcmet Filcs\Content.IE5\QWYIKUOI\ChangeOrderl_10-19-12.doe/AWah AJLS - City Clerk City Clerk Number CAGA 2-056 Checklist Select One: F Contract ❑ Permit ❑ Lease ❑ Agreement Contract Type (assigned by City Clerk) Staff Name: Andrew Weygandt Extension: x7208 Department/Division: Public Works - Water Utility EDEN Approval Queue: 05-007P Addendum Number: to City Clerk Number: Contract Class: ❑ Receivable X Payable ❑ Grant Contractor Name: B&B Utilities and Excavating, LLC CAG-12-056 (if applicable). ❑ Misc. (no $) Expiration Date: Short Description: SE 5th Street AC Water Main Replacement Project Full or Additional Description: Change Order 2. Additional pavement patching and equipment rental. ❑ Legal Review (attach memorandum from City Attorney) ❑ Risk Management review for insurance (attach memorandum from Risk Management) ❑ Insurance certificate and/or policy (attach original) ❑ Response to legal or Risk Management concerns (explain, in writing, how concerns have been met) ❑ Performance bond and verification memo from staff (for Public Works contracts only) ❑ Federal excluded parties list verification (Website: www.epls.gov, attach printout of search results) ❑ City business license number: BL.032377 Check EDEN or ask Finance Department. ❑ Accounts payable W-9 vendor form (obtain if not already on file with Finance Dept.) Submitted contracts are signed by contractor: ❑X Yes ❑ No If not, provide explanation below. Fiscal Impact: ❑X Expenditure or ❑ Revenue Amount Budgeted: Amount: $ 5,390.78 (line item; see below*): $ Prior Council approval via agenda bill process required if: (see policies 250-02 and 800-12) ❑ Contract or addendum is $20,000 or over (non -Public Works) or $30,000 or over (Public Works). ❑ * Contract expenditure amount exceeds budgeted amount; fund transfer needed. ❑ Addendum is for the second and additional time extensions. ❑ Interlocal Agreement (most Interlocal Agreements require Resolutions) Date of Council Approval: Resolution Number: (if applicable) (if applicable) 05/14;2012 Key words for City Clerk's electronic card file: 3E 5th Street, Maplewood 06/30/14 Contractor determined via: ❑ Phone Bid/Written Quote 0 CFB Ad ❑ Consultant Roster RFP/SOQ Ad ❑ Application ❑ Sole Source Print Form I Revised 07/23/2008 CITY OF RENTON Public Works Department CONTRACT CHANGE ORDER AGREEMENT CONTRACT: CAG 12-056 — SE 51h Street AC Water Main Replacement Project C.O.#2 CONTRACTOR: B&B Utilities and Excavating, LLC SUMMARY OF PROPOSED CHANGE: Provide all labor, equipment, subcontracting, bonding, insurance for the complete work required for the extra work as outlined below: ITEM Additional Quantities Under This Change Order Unit Quantity Unit Total Price CO2 Force Account work additional pavement patching and LS 1 $4,923.09 $4,923.09 sawcutting around exiting utility covers on SE 5th Street and additional equipment rental. Subtotal $4,923.09 9.5% Sales Tax $467.69 Total $5,390.78 ORIGINAL CONTRACT AMOUNT CURRENT CONTRACT AMOUNT ESTIMATED NET CHANGE THIS ORDER ESTIMATED CONTRACT TOTAL AFTER CHANGE $296,821.65 $279,321.01 $5,390.78 $284,711.79 Cost Allocation Water Utility 425.455596.018.595.34.63.000 $5,390.78 SIGNATURES Contractor: Project Engir Approved By Date: 1 _ I `I Date: /0 /i i 2 Date: C:\ilsers\Maulitta\AppData\Loca(\Microsoft\Windows\Temporary Intemet Files\Content.lE5\1N09RBZAChangeOrder2_10-19-12.doc/AWah SE 5th Street AC Water Main Replacement Project Contractor I B&B Utilities and Excavating, LLC Contract # Owner Date Pay Estimate No WTR-27-3604 City of Renton 10/30/2012 5 t .. [Demob • �i►l�I��1�I�I�I1I1It1 t t• t t t t 1/ 1' I i�l�I�I�I�I�I �1�►�Tral�_ic ComfiroolMiC =MMMI'�Ci1I1I1ItI1l t tt 1t tt 1 11'I C111'1 IWEE - _ . - .. ��i► 1I MEMI I1I1I1I11 tNMMMMZ 1• • • - _ . OEEMMMIM Mi�1�MEMI 1IIIsI1 - 1- • - • M�i'�11I1I1 I MINES100,.a 11011*1• -. MM ��MMMMIM�EMM1 C•1 11 • tt a •t. 1 11'I IMINNEZAIMIU, - Specific Potholing . •��'Y1I1s�1�NOMMI 11 11MMMIt A t - _ IIIQ KOM M . ►IN I - 311 E .1 MINIMS i1I1I11� t . • . t � A%' - - Tr alve - .TY MMII�l.�1IIIIIII�i�- ANaConcrete for Thrust Blocking, • .. Man Anchor Blocks-WEIMMIR 111 MENI 1I1I1I1Iq® t - � - iNydrant AssembAy�]ti�NEW II1I1I1I11MMIN ,. • t t t t t - �C� Relocate • - ' • . •WOiI��j.'11I1I1I11MMM§� „ t t - • - • • • ►t _ - t . . •' NOMINEE .•. •• •I1_- �_�i MMIN�Ci1I1I1I1I11®i ma's ttt - �.* -lect Imported Trench :. � 1 1 -1 :1 11 - �.�_ ' 11 �tiCi1I1I1I1I11- - CO' •1 •i1I1I17M c. E►•ji� - ••- • .•- '- • _ • 1�MMM'MINNi1I1I1I/I11MOMMEN6 rtt t 1 11•IMEN,:11 1/ 1=0 Rol 0 NOMINEE .. _ '• .1 11 • _ - : 1 -i�C�►1,!I.'i1I11 al tweal -iCI:�1I:i1Iej -M' • MMMIIENMMW� e� B&B Utilities and Excavating, LLC City of Renton Pay request Sales tax Total pay request 5% retention i otai due tnis pay request City of Renton Pay Request 5 Oct 30 12.xlsx Contractor SE 5th Street AC Water Main Replacement Project B&B Utilities and Excavating, LLC Contract # Owner Engineer Pay Estimate No Date WTR-27-3604 City of Renton City of Renton 1 08/07/12 Its ME MR9911 M-E �_ r • • - • • _ • �i►III i�i�11I1I1I1I1I11—_ 1 11' , i[IIIIII1 III_--- �I�� • • ��Ci1I1I1III1l�' C 1'I I I I __ 111' . i6'11IIIIIII---- - • . ��1��1:I1I1I:IU_— I I • . i67:I:III11_--- 1 • •. • . • • �5�1+��i:I:I:I1I�l_- 1 • - • ��i'NOMEIIII9 II-- MEMO • 1 / 1 ---- �- - • Erosion& Sedimentation• • l III � 1 I I -_ . I I I ' . NNNWA II11 _— -- - Specific Potholing ��I�OiII8IIII =- � I I IIIIII _--- E-- 11. - • - . • • MNNNNI 1 I .1 N I11/ICI:IIIIIII=— I I ��!I:11</III_--- � _ - V . - - • � W. Us 11 .19191I I _— I 1 �ipI1I1I11---- �' concrete for Thrust Blocking, Dead Man Anchor Blo—cksmNIME =$,I INIM", Wou, �JrZIMFIIEDW--Aywy, i'!•'i1I1ILII1__ 11 • I'I. 1' I _--- Install fire ' • _ - • �t11LLIILI��li:I1LLIIl-- ell) Relocate • Fire ' • _ 17�i�1=1 I��b'1:=�— 11 . rr. - - - • - • 17�i � NNN :I:=__ . II icicXi�:I:I:I_--- �� • - • • • rr. - r . ��r+��i[IIIIII:I:III�-- _--- _ • • • • ►1. - r . . �' I / 1 I ��lCiIIII1III1l_— I 1 ENNIIIIIIIIIII_--- �:S -lect Imported Trench : _ckfill 1 1 :11 :1 1 I _— C : ---- Surfacing Top Course & Crushed Rock Back NII—M� �111 NOW 9 1 ►�G' . - - � - .. . - - - . . `�`� 11 � .1 1:3��.'iII1IIl�-- _--- C{' • • • - • . • - - - • • i1I:III:III_-- _—_— subtotal $271,070.00 $17f,271.94 Pay request Tax 9.5% $25,751.65 Sales tax Total $296,821.65 $194,112.77 Total pay request 5% retention 1 otal aue this pay request X x B&B UbAs and Excavating, LLC City of Renton City of Renton Pay Request July 25, 2012.xlsx --LOADS-GOADS �JNCR��E, LLC Remittance Address: Phone: 206-498-1332 / MSTR Light Loads Concrete, LLC 206-323-9813 PO BOX 1494 Fax: 253-630-3254 Maple Valley, WA98038 «'ww. ightloadsconcrete.com �Z CI ^.St'CCticns: •Time Due Load ITo Job j On Job Begin Pour Finish Pour To Plant Plant Time In (Finish Wash Out j I I DATE:� i Plant Name / # Delivery Ticket ID Ordered By FOB Load Size Product code Quantity Quantity Description j Amount Ordered Delivered j I j • ADDITION OF WATER WILL REDUCE STRENGTH, WATER WATER ADDED ON SITE AUTHORIZED BY: SUBTOTAL ADDED AT CUSTOMER'S OWN RISK. • NOT RESPONSIBLE FOR COLOR VARIATIONS OR SURFACE GALS . T O FULL LOAD DISCOLORATION ON THIS LOAD OR MULTIPLE LOADS TO GALS To 2/3 LOAD SAME JOB SITE. Standby Time • WARNING IRRITATION TO SKIN AND EYES -SEE REVERSE. GALS TO I/2 LOAD Overtime SUBTOTAL AUTHORIZED BY: PRINT NAME SIGNATURE SIGNATURE ACKNOWLEDGES RECEIPT OF CONCRETE, WATER ADDITION, HAZARD WARNING, AND Tax Code /Tax ACCEPTANCE OF THE TERMS AND CONDITIONS PRINTED ON THE BACK OF THIS DOCUMENT. PRINT NAME: DATE: Balance Due CUSTOMER SIGNATURE: c,STONEWAY .✓ CONCRETE SEATTLE (Plant r" 3803 E. Marginal Wy S., Seattle TUKWILA (Plant -12-. 17,024 W. Valley Hwy.. Tukwila RENTON (Plant #14. St5 Hauser Way N., Renton ACCOUNTING: 9125 TENTH AVENUE SOUTH CEDAR SHORES (Piani 40j 21010 Cedar Grove Rd. S.E., Maple Valley SEATTLE, WA 98108 • (206) 762-2566 A DIVISION OF GARY MERLINO CONSTRUCTION COMPANY, INC. DELMERY TICKET ACCOUNTINGCOUNTING (206) 762-2566 FAX (206) 762-2358 SALES & ORDER DESK (425) 226-1000 TICKET TIME AM LEAVE PLANT ARRIVE JOB BEGIN POUR FINISH POUR LEAVE JOB ARRIVE PLANT PM DATE CUSTOMER NO. ORDER NO. PROJECT PLANT # CUSTOMER NAME CUSTOMER P.O. JOB NO. DELIVERY TICKET NO.� JOB ADDRESS ----- _- _ COLLECT ON DELIVERY (C.O.D.) ❑ CASH ❑ CHECK # []CHARGE MAP ZONE CARD # EXP. SPECIAL INSTRUCTIONS ❑ VISA ❑ MASTERCARD ❑ DISCOVER •UANTITY •� UCT . • R AAMOUNT I i JOB TOTAL SLUMP SPACING ORDERED BY • TRUCK N0. DRIVER • WATER ADDED ON -SITE CYLINDERS AUTHORIZED BY: I = YES � gals. to full load —YES REASON FOR DELAY TIME: gals. t0 2/3 load — JOB NOT READY ❑ LACK OF HELP ❑ ADDING WATER ❑ WHEEL BARROW JOB = YES ARRIVED JOB EARLY :1 TRAFFIC TRAIN ❑ DRAW BRIDGE gals. t0 1 /3 load - WAITING FOR TRUCK TO UNLOAD E PUMP BLOW -BACK NONE WAITING ON PUMP WASH PUMP OTHER ADDITION OF WATER WILL REDUCE - WARNING - RELEASE — CUSTOMER RE -EASES AND AGREES TO HOLD HARMLESS STONEWAY CONCRETE, IRRITATION TO A DIVISION OF GARY MERLINO CONSTRUCTION COMPANY, INC. FOR ANY DAMAGE TO HIS REAL STRENGTH. WATER ADDED AT SKIN AND EYES OR PERSONAL PROPERTY CAUSED BY DELIVERY OF MATERIALS LISTED ABOVE. DETAILS OF SITE CUSTOMER'S OWN RISK. SEE REVERSE (16) AGREEMENT ACCESS ON BACK (5). 6 MINUTES PER CUBIC YARD NOT RESPONSIBLE FOR COLOR CUSTOMER SIGNATURE UNLOADING TIME INCLUDED. VARIATION OR Additional unloading time charged at current hourly truck rate. SURFACE DISCOLORATION ------------------------------------------- PRINT NAME DATE BATCH DATA: TICKET TOTAL REV 06/08 NBF 4� ? C"Ol 'll �ox% CQ* RENTON CONCRETE RECYCLERS w2 t� 22121 17th Ave S.E. Suite #117 Bothell, WA 98021 cc ca j Pit Site: 500 Monster Road S.W. Renton, WA Business Office: 425-481-9101 YCScale House: 206-772-2278 �. FCL�Qa � _ / Ticket # 196720 Date: Customer: C Project Name/P.O. Number: Project Location (City, Street): Trucking Company: Cash Scaleperson: Account Truck# Time Material Gross Weight Tare Weight Net TonslYd3 Price Ma er al'Si a kf TERMS: NET 30 DAYS FROM END OF MONTH. A Finance Charge will e assessed on all past due accounts at a rate of 1 1/2% per month. Total Material Annual finance charge of 18% NOTICE: It is specifically a reed that this company shall not 5%Environmental Fee be in anyway responsibye for damage to customers property Sales Tax resutling from deliveries beyond the curb line. Total DRIVER SIGNATURE/PRINTED NAME: CO*, RENTON CONCRETE RECYCLERS 22121 17th Ave S.E. Suite #117 Bothell, WA 98021 cc cn Pit Site: 500 Monster Road S.W. Renton, WA Business Office: 425-481-9101 ��'CYCL�4y Q Scale House: 206-772-2278 414slLt Ticket # 196810 Date: Customer: Project Name/P.O. Number: Project Location (City, Street): Trucking Company: Scaleperson: Cash Account Truck# Time Material Gross Weight Tare Weight Net Tons[Yd3 Price MNet ate al'Sh a :31 , 11 Nr--,ryr( TERMS: NET 30 DAYS FROM END OF MONTH. A Finance Charge will e assessed on all past due accounts at a rate of 1 1/2% per month. Total Material Annual finance charge of 18% 5%Environmental Fee NOTICE: It is specifically a reed that this company shall not be in anyway responsibye for damage to customers property Sales Tax resutling from deliveries beyond the curb line. Total DRIVER SIGNATURE/PRINTED NAME: `6A 703A AGG KENMORE 7/11/2012 8:51:07 q 6423 NE 175TH STREET 1111I�I �IIII f/111 III KENMORE, WA 980284808 llll/ i/III t I111 Jill Customer 1005777 B&B UTILITIES Project: 7993 & EXCAVATING LLC P_O_: JOB 1230 Product. 8821 Job Number: 1230 Delv To 5/8" CG CSTC 6423 NE 175TH STREET KENMORE WA 98028 Hauler: 999 FOB PICKUP Truck: 8& B 1 S RECU By B & B UTIL BLUE #1 S DATE 63 CAL?pq�NQ NO: 579021 O"s1,V7 DEUVERT TOTALS LOAD - OTy 33 0 13 asp sy 1/1t201 SouRC nrryy DEBBIE 28:SYOfi AM Kenmore Ibs 42,780 tons THE 7/y2012 T5f'S3 AM Man Wr 21.39 19.40 cross 22, 520 11.26 10.21 Tare 20,260 10.13 9-19 Net P RO DUC T So 00 ENy FEE TAX $0.00 TOTAL Sn o0 703A AGG KENMORE 7/12/2012 12:34:14 6423 NE 175TH STREET KENMORE, WA 980284808 will �� 11111 111t1 1t111 11111 ruaoanarm fill ",I Customer: 1005777 NO: 579844 B&B UTILITIES & EXCAVATING LLC Project: 7993 0RqAW1 PICKED UP/AGG P.O.: JOB 1230 Job Number: 1230 °EUVER� �TOTA Product: 8821 5/8" CG CSTC � i Q"L Iv To. 40 6423 NE 175TH STREET ° i2ss 4szes Weighr�i er. MURPHY DEBBIEDATEDATE SOURCE KENMORE 711212012123412P Ke g WA 98028 Tons THE 48,440 1/g12p12 7�51 53 AM Man vvt 24.22 21.97 Gross 22.520 11.26 10.21 Tars O 25,920 12.96 11.76 No Hauler: 999 FOB PICKUP Truck: B&B1S B & B UTIL BLUE #1 S REWDBY DATE 7FR�E40HT KANGLEY ROCK & RECYCLING ACCOUNTING: 9125 TENTH AVENUE SOUTH SEATTLE, WA 98108 • (206) 762-2566 A DIVISION OF GARY MERLINO CONSTRUCTION COMPANY. INC. KANGLEY PIT (Plant # 021) 32500 S.E. Kent-Kangley Rd., Ravensdale, WA 98051 • (360) 886-9269 BLACK RIVER QUARRY (Plant # 022) 510 Monster Road, Renton. WA 98055 • (425) 226-1000 ext. 3339 CEDAR SHORES (Plant # 020) — 21010 Cedar Grove Road S.E., Maple Valley, WA 98038 • (425) 226-1000 ext. 3340 DELIVERY TICKET ACCOUNTING (206) 762 2566 FAX (206) 762-2358 SALES & ORDER DESK (425) 226-1000 MAP LOCATE LEAVE PLANT ARRIVE JOB LEAVE JOB ARRIVE PLANT DATE CUSTOMER NO. ORDER NO. PROJECT PLANT # CUSTOMER NAME CUSTOMER P.O. JOB NO. DELIVERY TICKET NO. JOB ADDRESS COLLECT ON DELIVERY (C.O.D.) ❑ CASH CHECK # L] CHARGE CARD # EXR SPECIAL INSTRUCTIONS VISA MASTERCARD ❑ DISCOVER • •� • DESCRIPTION • • DRIVER TRUCK NO. ORDERED BY • • 1 DISPATCHER TAX CODE TIME DUE 1 SALES TAX RELEASE — CUSTOMER RELEASES AND AGREES TO HOLD HARMLESS KANGLEY ROCK & RECYCLING, A DIVISION OF GARY MERLINO CONSTRUCTION COMPANY, INC. FOR ANY DAMAGE TO HIS REAL OR PERSONAL PROPERTY BALANCE FORWARD CAUSED BY DELIVERY OF MATERIALS LISTED ABOVE. DETAILS ON REVERSE. CUSTOMER SIGNATURE _TOTAL AMOUNT PRINT NAME ( DATE REV 04/2009 TRIO CUSTOMER COPY TERMS, CONDITIONS AND WARNINGS 1. CREDIT. Condition precedent to Seller's obligation to perform any and all credit terms of payment must be set forth in this Contract. In the absence of any such credit terms, all deliveries under this Contract are "Collect On Delivery" (C.O. Lurchaser agrees upon request to furnish Seller such information as is reasonably necessary for Seller to determine Purchaser's financial condition. Sel obflgation to perform under this Contract is subject to the condition precedent that Seller shall have thirty (30) days fromj fceipt of the executed Contract from Purchaser so that Seller's credit department may review and approve or disapprove any credit terms of paymentcified in this Contract. 2. TERMS OF PAYMENT. All invoices*e due for . ettt by the 30th day after the date of invoice. Service charges of one and one -quarter percent (1.25%) per month will be payable on all past due invoices of thirty (30) days or older. If a service charge is assessed, it must be paid in order to maintain an open account. Purchaser shall make all payments dik hereunder in lawful money of the United States and in accordance with the terms hereof, without any retention and without regard to any agreement Purchaser may have with other parties. Should legal action be initiated to collect this invoice, the prevailing party shall be entitled to recover reasonable attorney fees and costs, including appeals. bankruptcies, and post -judgement qplWction efforts. Venue and jurisdiction of any suit or legal actio may be had in Seattle, King County. Washington at the sole option of Seller. This agreement II beconstrued and enforced in accordance with the I?ws of the State of Washington. KANGLEY ROCK & RECYCLING ROUTINELY EXERCISES THEIR RIGHT TO SEND MATERIALMAN'S NOTICES TO ALL JOBS. 3. TAXES. All federal, state and local taxes, asses§ments, fees, duties and charges levied by reason of this Proposal are in addition to prices quoted herein and shall be paid by Purchaser. 4. DELIVERY CONDITIONS. Signed Purchaser h4AVequested Kangley Rock & Recycling. a Division of Gary Merlino Construction Company. Inc. (Seller) to make use of a path for the delivery of materials and access to the project requiring trucks to travel beyond the boundaries of the nearest traveled public highway. Seller has advised that due to the size and weight of trucks, dan*e to the premises and/or adjacent propertyr or personal injury may occur and that trucks may become damaged, disabled or stuck if Seller makes use of the path requested. Seller has further advised that it is their policy that deliveries requiring Seller's trucks travel beyond the nearest highway to obtain access to the job site are at the risk of the Purchaser and that Seiler assumes no liability for property damage or personal injury that may result. Purchaser agrees to assume responsibility to Seller and third parties for property damage, personal injuries, truck towing and winching expenses. and/or damage to Seller's trucks should the trucks become damaged, disabled or stuck as a result of Seller making use of the path requested or for the delivery of materials and access to the project site. Purchaser also agrees to indemnify, hold harmless, and defend Seller from any claims, demands, losses, and liabilities to or by third parties arising from, resulting from, or connected with the use of the requested path for the delivery of materials whether such claims may prove to be true or false, groundless or fraudulent, to the full extent permitted by lava and subject to the limitations below. Purchaser's duty to indemnify Seller for liability for damages arising out of bodily injury to persons or damage to property caused by or resulting from the concurrent negligence of (a) Kangley Rock & Recycling, a Division of Gary Merlino Construction Company. Inc. or its agents and employees, and (b) the Purchaser shall apply only to the extent of the negligence of the Purchaser or its agents and employees. For the purpose of the Purchaser's indemnification obligation only, the Purchaser specifically and expressly waives any immunity that may be granted it under the Washington State Industrial Insurance Act.. Title 51 RCW. This waiver does not permit a direct action by the Purchaser's employees against the Purchaser. Further, the indemnification obligation under this Agreement shall not be limited in any way by any limitation on the amount or type of damages, compensation or benefits payable to or for any third party under worker's compensation acts, disability benefit acts, or their employee benefit acts. This promise of indemnity specifically applies in the case of injuries to the undersigned's own employees. The undersigned's duty to defend. indemnify and hold Seller harmless shall include, as to all claims, demands. losses, and liability to which it applies, Seller's personnel related costs. reasonable attorney's fees, court costs, and all other claim -related expenses, including attorney's fees and other costs incurred by Seller to enforce and establish its right under this Agreement. Upon Seller's tender of defense under this Agreement, the Purchaser agrees to appoint counsel of Seller's choice to defend against third party claim(s). Such counsel will be at the sole expense of the Purchaser. Seller is not responsible for means and methods of placement of ready mixed concrete or aggregate products on a project. 5. LIMITATION ON DAMAGES. Seller assumes no responsibility for, and shall not be liable to, Purchaser for any consequential damages incurred by Purchaser in connection with this Contract, including without limitation, Purchaser's lost profits. Purchaser's good will. and any injury to person or property proximately resulting from any breach by Seller or breach of warranty by Seller. 6. CLAIMS AND BACK CHARGES. Purchasers exclusive procedure for commencing claims under this Contract against Seller for any reason, including breach of contract or breach of warranty, shall be as follows: Notice of claims against Seller for any reason, including but not limited to. breach of contract or warranty, must be given to Seller in writing within three (3) working days after discovery or when discovery should have been made. The written claim shall include the reason(s) and grounds for the claim and the dollar amount or relief sought. FAILURE OF PURCHASER TO GIVE SUCH NOTICE WITHIN THREE (3) WORKING DAYS SHALL CONSTITUTE A WAIVER BY PURCHASER OF ITS RIGHT TO LATER MAKE ANY SUCH CLAIM. If a dispute arises and cannot be resolved. the parties involved agree to binding arbitration through non -legal personnel. 7. TITLE AND RISK OF LOSS. Unless otherwise expressly stated herein, title to the materials sold hereunder shall remain with Seller until Seller has received full payment for the same. Risk of loss of the materials sold under this Contract shall pass to the Purchaser upon delivery of the same, at the place of delivery designated herein. Thereafter, in addition to assuming all risk of loss, Purchaser shall be responsible for compliance with all governmental regulations and ordinances with regard to storage or placement of the same and shall indemnify and hold Seller harmless against all claims for personal injuries, including death, and property damage arising from the storage. use or handling of said materials. KANGLEY ROCK & RECYCLING ACCOUNTING: 9125 TENTH AVENUE SOUTH SEATTLE, WA 98108 • (206) 762-2566 A DIVISION OF GARY MERLINO CONSTRUCTION COMPANY, INC. KANGLEY PIT (Plant # 021) 32500 S.E. Kent-Kangley Rd., Ravensdale, WA 98051 • (360) 886-9269 BLACK RIVER QUARRY (Plant # 022) 510 Monster Road. Renton, WA 98055 • (425) 226-1000 ext. 3339 CEDAR SHORES (Plant # 020) — 21010 Cedar Grove Road S.E., Maple Valley, WA 98038 • (425) 226-1000 ext. 3340 DELIVERY TICKET ACCOUNTING (206) 762 2566 FAX (206) 762-2358 SALES & ORDER DESK (425) 226-1000 MAP LOCATE LEAVE PLANT ARRIVE JOB LEAVE JOB ARRIVE PLANT DATE CUSTOMER NO. ORDER NO. PROJECT PLANT # CUSTOMER NAME CUSTOMER P.O. JOB NO. DELIVERY TICKET NO. JOB ADDRESS COLLECT ON DELIVERY (C.O.D.) ❑ CASH CHECK # ❑ CHARGE CARD # EXP. SPECIAL INSTRUCTIONS ❑ VISA _ MASTERCARD ❑ DISCOVER • DESCRIPTION • • •� • DRIVER TRUCK NO. ORDERED BY • SUB -TOTAL 1 DISPATCHER TAX CODE TIME DUE 1 SALES TAX RELEASE — CUSTOMER RELEASES AND AGREES TO HOLD HARMLESS KANGLEY ROCK & RECYCLING, A DIVISION OF GARY MERLINO CONSTRUCTION COMPANY, INC. FOR ANY DAMAGE TO HIS REAL OR PERSONAL PROPERTY • • CAUSED BY DELIVERY OF MATERIALS LISTED ABOVE. DETAILS ON REVERSE. CUSTOMER SIGNATURE • PRINT NAME DATE—, I REV 04/2009 TRIO CUSTOMER COPY TERMS, CONDITIONS AND WARNINGS 1. CREDIT. Condition precedent to Seller's obligation to perform any and all credit terms of payment must be set forth in this Contract. 'In the absence of any such credit terns, all deliveries under this Contract are "Collect On Delivery" (C.O.D.). Purchaser agrees upon request to furnish Seller such information as is reasonably necessary for Seller to determine Purchaser's financial condition. Wler's obligation to perform under this Contract is subject to the condition precedent that Seller shall have thirty (30) days from receipt of the executed Odhtract from Purchaser so that Seller's credit department may review and approve or disapprove any credit terms of payment specified in this Contract. 2. TERMS OF PAYMENT. All invoices are due for payment by the 30th day after the date of invoice. Service charges of one and one -quarter percent (1.25%) per month will be payable on all past due invoices of thirty (30) days or older. If a service charge is assessed. it must be paid in order to maintain an open account. Purchaser shall make all payments due hereunder in lawful money of the United States and in accordance with the terms hereof, without any retention and without regard to any agreement Purchaser may have with other parties. Should legal action be initiated to collect this invoice, the prevailing party shall be entitled to recover reasonable attorney fees and costs, including appeals, bankruptcies. and post-judgernent collection efforts. Venue and jurisdiction of any suit or legal action may be had in Seattle, King County, Washington at the sole option of Seller. This agreement shall be construed and enforced in accordance with the laws of the State of Washington. KANGLEY ROCK & RECYCLING ROUTINELY EXERCISES THEIR RIGHT TO SEND MATERIALMAN'S NOTICES TO ALL JOBS. 3. TAXES. All federal, state and local taxes, assessments, fees, duties and charges levied by reason of this Proposal are in addition to prices quoted herein and shall be paid by Purchaser. 4. DELIVERY CONDITIONS. Signed Purchaser has requested Kangley Rock & Recycling, a Division of Gary Merlino Construction Company, Inc. (Seller) to make use of a path for the delivery of materials and access to the project requiring trucks to travel beyond the boundaries of the nearest traveled public highway. Seller has advised that due to the size and weight of trucks, damage to the premises and/or adjacent property, or personal injury may occur and that trucks may become damaged, disabled or stuck if Seller makes use of the path requested. Seller has further advised that it is their policy that deliveries requiring Seller's trucks travel beyond the nearest highway to obtain access to the job site are at the risk of the Purchaser and that Seller assumes no liability for property damage or personal injury that may result. Purchaser agrees to assume responsibility to Seller and third parties for property damage, personal injuries, truck towing and winching expenses, and/or damage to Seller's trucks should the trucks become damaged, disabled or stuck as a result of Seller making use of the path requested or for the delivery of materials and access to the project site. Purchaser also agrees to indemnify, hold harmless. and defend Seller from any claims, demands, losses, and liabilities to or by third parties arising from, resulting from, or connected with the use of the requested path for the delivery of materials whether such claims may prove to be true or false, groundless or fraudulent, to the full extent permitted by law and subject to the limitations below. Purchaser's duty to indemnify Seller for liability for damages arising out of bodily injury to persons or damage to property caused by or resulting from the concurrent negligence of (a) Kangley Rock & Recycling, a Division of Gary Merino Construction Company, Inc. or its agents and employees, and (b) the Purchaser shall apply only to the extent of the negligence of the Purchaser or its agents and employees. For the purpose of the Purchaser's indemnification obligation only. the Purchaser specifically and expressly waives any immunity that may be granted it under the Washington State Industrial Insurance Act, Title 51 RCW. This waiver does not permit a direct action by the Purchaser's employees against the Purchaser. Further, the indemnification obligation under this Agreement shall not be limited in any way by any limitation on the amount or type of damages. compensation or benefits payable to or for any third party under worker's compensation acts. disability benefit acts, or their employee benefit acts. This promise of indemnity specifically applies in the case of injuries to the undersigned's own employees. The undersigned's duty to defend, indemnify and hold Seller harmless shall include, as to all claims, demands, losses, and liability to which it applies, Seller's personnel related costs, reasonable attorney's fees, court costs. and all other claim -related expenses, including attorneys fees and other costs incurred by Seller to enforce and establish its right under this Agreement. Upon Seller's tender of defense under this Agreement, the Purchaser agrees to appoint counsel of Seller's choice to defend against third party claim(s). Such counsel will be at the sole expense of the Purchaser. Seller is not responsible for means and methods of placement of ready mixed concrete or aggregate products on a project. 5. LIMITATION ON DAMAGES. Seller assumes no responsibility for, and shall not be liable to, Purchaser for any consequential damages incurred by Purchaser in connection with this Contract, including without limitation. Purchaser's lost profits, Purchaser's good will, and any injury to person or property proximately resulting from any breach by Seller or breach of warranty by Seller. 6. CLAIMS AND BACK CHARGES. Purchaser's exclusive procedure for commencing claims under this Contract against Seller for any reason, including breach of contract or breach of warranty. shall be as follows: Notice of claims against Seller for any reason, including but not limited to, breach of contract or warranty, must be given to Seller in writing within three (3) working days after discovery or when discovery should have beer, made. The written claim shall include the reason(s) and grounds for the claim and the dollar amount or relief sought. FAILURE OF PURCHASER TO GIVE SUCH NOTICE WITHIN THREE (3) WORKING DAYS SHALL CONSTITUTE A WAIVER BY PURCHASER OF ITS RIGHT TO LATER MAKE ANY SUCH CLAIM. If a dispute arises and cannot be resolved, the parties involved agree to binding arbitration through non -legal personnel. 7. TITLE AND RISK OF LOSS. Unless otherwise expressly stated herein, title to the materials sold hereunder shall remain with Seller until Seller has received full payment for the same. Risk of loss of the materials sold under this Contract shall pass to the Purchaser upon delivery of the same, at the place of delivery designated herein. Thereafter, in addition to assuming all risk of loss, Purchaser shall be responsible for compliance with all governmental regulations and ordinances with regard to storage or placement of the same and shall indemnify and hold Seller harmless against all claims for personal injuries, including death. and property damage arising from the storage, use or handling of said materials. L) KANGLEY KANGLEY PIT (Plant # 021) DELIVERY TICKET 32500 S.E. Kent KRd.. avenstlale, WA 98051 (360) 886 9269 ROCK & RECYCLING ACCOUNTING (206) 7t.. -2566 BLACK RIVER QUARRY (Plant # 022) ACCOUNTING: 9125 TENTH AVENUE SOUTH 510 Monster Road, Renton, WA 98055 • (425) 226-1000 ext. 3339 FAX (206) 762-2358 SEATTLE, WA 98108 • (206) 762-2566 CEDAR SHORES (Plant # 020) — 21010 Cedar Grove Road S.E., SALES & A DIVISION OF GARY MERLINO CONSTRUCTION COMPANY, INC. Maple Valley, WA 98038 • (425) 226-1000 ext. 3340 ORDER DESK (425) 226-1000 MAP LOCATE LEAVE PLANT ARRIVE JOB LEAVE JOB ARRIVE PLANT DATE CUSTOMER NO. ORDER NO. PROJECT PLANT # CUSTOMER NAME CUSTOMER P.O. JOB NO. DELIVERY TICKET NO. JOB ADDRESS COLLECT ON DELIVERY (C.O.D.) ❑ CASH - CHECK # ❑ CHARGE CARD # EXP. SPECIAL INSTRUCTIONS VISA MASTERCARD ❑ DISCOVER DESCRIPTION DRIVER TRUCK NO. ORDERED BY • • I DISPATCHER TAX CODE TIME bUE 1 • RELEASE — CUSTOMER RELEASES AND AGREES TO HOLD HARMLESS KANGLEY ROCK & RECYCLING, A DIVISION OF GARY MERLINO CONSTRUCTION COMP�1tyY, INC. FOR ANY DAMAGE TO HIS REAL OR PERSONAL PROPERTY CAUSED BY DELIVERY OF MATERIALS t1SZBOVE. DETAILS ON REVERSE. • ' ' • CUSTOMER SIGNATURE • • PRINT NAME DATE REV 04/2009 TRIO CUSTOMER COPY TERMS, CONDITIONS AND WARNINGS 1. CREDIT. Condition precedent to Seller's obligation to perform any and all credit terms of payment must be set forth in this Contract. In the absence of any such credit terms, all deliveries under this Contract are "Collect On Delivery" (C.O.D.). Purchaser agrees upon request to furnish Seller such information as is reasonably necessary for Seller to determine Purchaser's financial condition. Seller's obligation to perform under this Contract is subject to the condition precedent that Seller shall have thirty (30) days from receipt of the executed Contract from Purchaser so that Seller's credit department may review and approve or disapprove any credit terms of payment specified in this Contract. 2. TERMS OF PAYMENT. All invoices are due for payment by the 30th day after the date of invoice. Service charges of one and one -quarter percent (1.25%) per month will be payable on all past due invoices of thirty (30) days or older. If a service charge is assessed, it must be paid in order to maintain an open account. Purchaser shall make all payments due hereunder in lawful money of the United States and in accordance with the terms hereof, without any retention and without regard to any agreement Purchaser may have with other parties. Should legal action be initiated to collect this invoice, the prevailing party shall be entitled to recover reasonable attorney fees and costs, including appeals. bankruptcies, and post -judgement collection efforts. Venue and jurisdiction of any suit or legal action may be had in Seattle, King County, Washington at the sole option of Seller. This agreement shall be construed and enforced in accordance with the laws of the State of Washington. KANGLEY ROCK & RECYCLING ROUTINELY EXERCISES THEIR RIGHT TO SEND MATERIALMAN'S NOTICES TO ALL JOBS. 3. TAXES. All federal, state and local taxes, assessments, fees, duties and charges levied by reason of this Proposal are in addition to prices quoted herein and shall be paid by Purchaser. 4. DELIVERY CONDITIONS. Signed Purchaser has requested Kangley Rock & Recycling, a Division of Gary Merlino Construction Company, Inc. (Seller) to make use of a path for the delivery of materials and access to the project requiring trucks to travel beyond the boundaries of the nearest traveled public highway. Seller has advised that due to the size and weight of trunks, damage to the premises and/or adjacent property, or personal injury may occur and that trucks may become damaged, disabled or stuck if Seller makes use of the path requested. Seller has further advised that it is their policy that deliveries requiring Seller's trucks travel beyond the nearest highway to obtain access to the job site are at the risk of the Purchaser and that Seller assumes no liability for property damage or personal injury that may result. Purchaser agrees to assume responsibility to Seller and third parties for property damage, personal injuries. track towing and winching expenses. and/or damage to Seller's trucks should the trucks become damaged, disabled or stuck as a result of Seller making use of the path requested or for the delivery of materials and access to the project site. Purchaser also agrees to indemnify, hold harmless, and defend Seller from any claims, demands, losses, and liabilities to or by third parties arising from, resulting from, or connected with the use of the requested path for the delivery of materials whether such claims may prove to be true or false, groundless or fraudulent, to the full extent permitted by law and subject to the limitations below. Purchaser's duty to indemnify Seller for liability for damages arising out of bodily injury to persons or damage to property caused by or resulting from the concurrent negligence of (a) Kangley Rock & Recycling, a Division of Gary Merlino Construction Company, Inc. or its agents and employees, and (b) the Purchaser shall apply only to the extent of the negligence of the Purchaser or its agents and employees. For the purpose of the Purchaser's indemnification obligation only, the Purchaser specifically and expressly waives any immunity that may be granted it under the Washington State Industrial Insurance Act, Title 51 RCW. This waiver does not permit a direct action by the Purchaser's employees against the Purchaser. Further, the indemnification obligation under this Agreement shall not be limited in any way by any limitation on the amount or type of damages. compensation or benefits payable to or for any third party under worker's compensation acts, disability benefit acts, or their employee benefit acts. This promise of indemnity specifically applies in the case of injuries to the undersigned's own employees. The undersigned's duty to defend, indemnify and hold Seller harmless shall include, as to all claims, demands, losses, and liability to which it applies, Seller's personnel related costs, reasonable attorney's fees. court costs, and all other claim -related expenses, including attorney's fees and other costs incurred by Seller to enforce and establish its right under this Agreement. Upon Seller's tender of defense under this Agreement, the Purchaser agrees to appoint counsel of Seller's choice to defend against third party claim(s). Such counsel will be at the sole expense of the Purchaser. Seller is not responsible for means and methods of placement of ready mixed concrete or aggregate products on a project. 5. LIMITATION ON DAMAGES. Seller assumes no responsibility for, and shall not be liable to. Purchaser for any consequential damages incurred by Purchaser in connection with this Contract. including without limitation, Purchaser's lost profits, Purchaser's good will, and any injury to person or property proximately resulting from any breach by Seller or breach of warranty by Seller. 6. CLAIMS AND BACK CHARGES. Purchaser's exclusive procedure for commencing claims under this Contract against Seller for any reason, including breach of contract or breach of warranty, shall be as follows: Notice of claims against Seller for any reason, including but not limited to, breach of contract or warranty, must be given to Seller in writing within three (3) working days after discovery or when discovery should have been made. The written claim shall include the reason(s) and grounds for the claim and the dollar amount or relief sought. FAILURE OF PURCHASER TO GIVE SUCH NOTICE WITHIN THREE (3) WORKING DAYS SHALL CONSTITUTE A WAIVER BY PURCHASER OF ITS RIGHT TO LATER MAKE ANY SUCH CLAIM. If a dispute arises and cannot be resolved, the parties involved agree to binding arbitration through non -legal personnel. 7. TITLE AND RISK OF LOSS. Unless otherwise expressly stated herein, title to the materials sold hereunder shall remain with Seller until Seller has received full payment for the same. Risk of loss of the materials sold under this Contract shall pass to the Purchaser upon delivery of the same. at the place of delivery designated herein. Thereafter. in addition to assuming all risk of loss, Purchaser shall be responsible for compliance with all governmental regulations and ordinances with regard to storage or placement of the same and shall indemnify and hold Seller harmless against all claims for personal injuries, including death, and property damage arising from the storage, use or handling of said materials. KANGLEY KANGLEY PIT (Plant # 021) DELIVERY TICKET 32500 S.E. Kent-Kangley Rd., Ravensdale. WA 98051 • (360) 886-9269 ROCK & RECYCLING ACCOUNTING (206) 762-2566 BLACK RIVER QUARRY (Plant # 022) ACCOUNTING: 9125 TENTH AVENUE SOUTH 510 Monster Road, Renton, WA 98055 • (425) 226-1000 ext. 3339 FAX (206) 762-2358 SEATTLE. WA 98108 • (206) 762-2566 CEDAR SHORES (Plant # 020) — 21010 Cedar Grove Road S.E.. SALES & A DIVISION OF GARY MERLINO CONSTRUCTION COMPANY, INC. Maple Valley, WA 98038 (425) 226-1000 ext. 3340 ORDER DESK (425) 226-1000 MAP LOCATE LEAVE PLANT ARRIVE JOB LEAVE JOB ARRIVE PLANT DATE CUSTOMER NO. ORDER NO. PROJECT PLANT # CUSTOMER NAME CUSTOMER P.O. JOB NO. DELIVERY TICKET NO. JOB ADDRESS COLLECT ON DELIVERY (C.O.D.) -1 CASH = CHECK # ` CHARGE CARD # EXP. SPECIAL INSTRUCTIONS ❑ VISA ❑ MASTERCARD ❑ DISCOVER DESCRIPTION 0 7 DRIVER TRUCK NO. ORDERED BY • • 1 DISPATCHER TAX CODE TIME DUE 1 : • RELEASE —CUSTOMER RELEASES AND AGREES TO HOLD HARMLESS KANGLEY ROCK 8 RECYCLING, A DIVISION OF GARY MERLINO CONSTRUCTION COMPANY, INC. FOR ANY DAMAGE TO HIS REAL OR PERSONAL PROPERTY • • • • CAUSED BY DELIVERY OF MATERIALS LISTED ABOVE, DETAILS ON REVERSE. CUSTOMER SIGNATURE • • PRINT NAME DATE REV 04/2009 TRIO CUSTOMER COPY TERMS, CONDITIONS AND WARNINGS 1. CREDIT. Condition precedent to Seller's obligation to perform any and all credit terns of payment must be set forth in this Contract. In the absence of any such credit terms, all deliveries under this Contract are "Collect On Delivery" (C.O.D.). Purchaser agrees upon request to furnish Seller such information as is reasonably necessary for Seller to determine Purchaser's financial condition. Seller's obligation to perform under this Contract is subject to the condition precedent that Seller shall have thirty (30) days from receipt of the executed Contract from Purchaser so that Seller's credit department may review and approve or disapprove any credit terms of payment specified in this Contract. 2. TERMS OF PAYMENT. All invoices are due for payment by the 30th day after the date of invoice. Service charges of one and one -quarter percent (1.25%) per month will be payable on all past due invoices of thirty (30) days or older. If a service charge is assessed, it must be paid in order to maintain an open account. Purchaser shall make all payments due hereunder in lawful money of the United States and in accordance with the terms hereof, without any retention and without regard to any agreement Purchaser may have with other parties. Should legal action be initiated to collect this invoice, the prevailing party shall be entitled to recover reasonable attorney fees and costs, including appeals, bankruptcies, and post -judgement collection efforts. Venue and jurisdiction of any suit or legal action may be had in Seattle, King County, Washington at the sole option of Seller. This agreement shall be construed and enforced in accordance with the laws of the State of Washington. KANGLEY ROCK & RECYCLING ROUTINELY EXERCISES THEIR RIGHT TO SEND MATERIALMAN'S NOTICES TO ALL JOBS. 3. TAXES. All federal, state and local taxes, assessments, fees, duties and charges levied by reason of this Proposal are in addition to prices quoted herein and shall be paid by Purchaser. 4. DELIVERY CONDITIONS. Signed Purchaser has requested Kangley Rock & Recycling, a Division of Gary Merlino Construction Company, Inc. (Seller) to make use of a path for the delivery of materials and access to the project requiring trucks to travel beyond the boundaries of the nearest traveled public highway. Seller has advised that due to the size and weight of trucks, damage to the premises and/or adjacent property, or personal injury may occur and that trucks may become damaged, disabled or stuck if Seller makes use of the path requested. Seller has further advised that it is their policy that deliveries requiring Seller's trucks travel beyond the nearest highway to obtain access to the job site are at the risk of the Purchaser and that Seller assumes no liability for property damage or personal injury that may result. Purchaser agrees to assume responsibility to Seller and third parties for property damage, personal injuries, truck towing and winching expenses, and/or damage to Seller's trucks should the trucks become damaged, disabled or stuck as a result of Seller making use of the path requested or for the delivery of materials and access to the project site. Purchaser also agrees to indemnify. hold harmless, and defend Seller from any claims, demands, losses, and liabilities to or by third parties arising from, resulting from, or connected with the use of the requested path for the delivery of materials whether such claims may prove to be true or false, groundless or fraudulent, to the full extent permitted by law and subject to the limitations below. Purchaser's duty to indemnify Seller for liability for damages arising out of bodily injury to persons or damage to property caused by or resulting from the concurrent negligence of (a) Kangley Rock & Recycling, a Division of Gary Merlino Construction Company, Inc. or its agents and employees, and (b) the Purchaser shall apply only to the extent of the negligence of the Purchaser or its agents and employees. For the purpose of the Purchaser's indemnification obligation only, the Purchaser specifically and expressly waives any immunity that may be granted it under the Washington State Industrial Insurance Act, Title 51 RCW. This waiver does not permit a direct action by the Purchaser's employees against the Purchaser. Further, the indemnification obligation under this Agreement shall not be limited in any way by any limitation or, the amount or type of damages, compensation or benefits payable to or for any third party under worker's compensation acts. disability benefit acts, or their employee benefit acts. This promise of indemnity specifically appiies in the case of injuries to the undersigned's own employees. The undersigned's duty to defend, indemnify and hold Seller harmless shall include, as to all claims, demands, losses, and liability to which it applies, Seller's personnel related costs, reasonable attorney's fees, court costs. and all other claim -related expenses, including attorney's fees and other costs incurred by Seller to enforce and establish its right under this Agreement. Upon Seller's tender of defense under this Agreement, the Purchaser agrees to appoint counsel of Seller's choice to defend against third party Jaim(s). Such counsel will be at the sole expense of the Purchaser. Seller is not responsible for means and methods of placement of ready mixed concrete or aggregate products on a project. 5. LIMITATION ON DAMAGES. Seller assumes no responsibility for, and shall not be liable to. Purchaser for any consequential damages incurred by Purchaser in connection with this Contract, including without limitation, Purchaser's lost profits, Purchaser's good will, and any injury to person or property proximately resulting from any breach by Seller or breach of warranty by Seller. 6, CLAIMS AND BACK CHARGES. Purchaser's exclusive procedure for commencing claims under this Contract against Seller for any reason, including breach of contract or breach of warranty, shall be as follows: Notice of claims against Seller for any reason, including but not limited to, breach of contract or warranty, must be given. to Seller in writing within three (3) working days after discovery or when discovery should have been made. The written claim shall include the reason(s) and grounds for the claim and the dollar amount or relief sought. FAILURE OF PURCHASER TO GIVE SUCH NOTICE WITHIN THREE (3) WORKING DAYS SHALL CONSTITUTE A WAIVER BY PURCHASER OF ITS RIGHT TO LATER MAKE ANY SUCH CLAIM. if a dispute arises and cannot be resolved, the parties involved agree to binding arbitration through non -legal personnel. 7. TITLE AND RISK OF LOSS. Unless otherwise expressly stated herein, title to the materials sold hereunder shall remain with Seller until Seller has received full payment for the same. Risk of loss of the materials sold under this Contract shall pass to the Purchaser upon delivery of the same. at the place of delivery designated herein. Thereafter, in addition to assuming all risk of loss, Purchaser shall be responsible for compliance with all governmental regulations and ordinances with regard to storage or placement of the same and shall indemnify and hold Seller harmless against all claims for personal injuries, including death, and property damage arising from the storage, use or handling of said materials. KANGLEY KANGLEY PIT (Plant # 021) DELIVERY TICKET 32500 S.E. Kent-Kangley Rd., Ravensdale. WA 98051 • (360) 886-9269 ROCK & RECYCLING ACCOUNTING i 2566 BLACK RIVER QUARRY (Plant # 022) (206) ACCOUNTING, 9125 TENTH AVENUE SOUTH 510 Monster Road, Renton, WA 98055 • (425) 226-1000 ext. 3339 FAX (206) 762-2358 SEATTLE, WA 98108 • (206) 762-2566 CEDAR SHORES (Plant # 020) — 21010 Cedar Grove Road S.E., SALES & A DIVISION OF GARY MERLINO CONSTRUCTION COMPANY. INC. Maple Valley, WA 98038 (425) 226-1000 ext. 3340 ORDER DESK (425) 226-1000 MAP LOCATE LEAVE PLANT ARRIVE JOB LEAVE JOB ARRIVE PLANT DATE CUSTOMER NO. ORDER NO. PROJECT PLANT # CUSTOMER NAME CUSTOMER P.O. JOB NO. DELIVERY TICKET NO. JOB ADDRESS COLLECT ON DELIVERY (C.O.D.) r CASH = CHECK # _ CHARGE CARD # EXP. SPECIAL INSTRUCTIONS VISA Ej— MASTERCARD -1 DISCOVER • •� DESCRIPTION • • • L' DPIVER TRUCK NO. ORDERED BY • • 1 DISPATCHER TAX CODE TIME DUE 1 RELEASE -- CUSTOMER RELEASES AND AGREES TO HOLD HARMLESS KANGLEY ROCK CYCLING, A DIVISION OF GARY MERLINO CONSTRUCT160 COMPANY, INC. FOR ANY DAMAGE TO HIS REAL PERSONAL PROPERTY • ' ' • CAUSED BY DELIVERY OF MATERIALS LISTED ABOVE. DETAILS'ON REVEfjSE. CUSTOMER SIGNATURE: • • PRINT NAME DATE i REV 04/2009 TRIO CUSTOMER COPY TERMS, CONDITIONS AND WARNINGS 1. CREDIT. Condition precedent to Seller's obligation to perform any and all credit terms of payment must be set forth in this Contract. In the absence of any such credit terms, all deliveries under this Contract are "Collect On Delivery" (C.O.D.). Purchaser agrees upon request to furnish Seller such information as is reasonably necessary for Seller to determine Purchaser's financial condition. Seller's obligation to perform under this Contract is subject to the condition precedent that Seller shall have thirty (30) days from receipt of the executed Contract from Purchaser so that Seller's credit department may review and approve or disapprove any credit terms of payment specified in this Contract. 2. TERMS OF PAYMENT. All invoices are due for payment by the 30th day after the date of invoice. Service charges of one and one -quarter percent (1.25%) per month will be payable on all past due invoices of thirty (30) days or older. If a service charge is assessed, it must be paid in order to maintain an open account. Purchaser shall make all payments due hereunder in lawful money of the United States and in accordance with the terms hereof, without any retention and without regard to any agreement Purchaser may have with other parties. Should legal action be initiated to collect this invoice. the prevailing party shall be entitled to recover reasonable attorney fees and costs, including appeals. bankruptcies, and post -judgement collection efforts. Venue and jurisdiction of any suit or legal action may be had in Seattle, King County, Washington at the sole option of Seller. This agreement shall be construed and enforced in accordance with the laws of the State of Washington. KANGLEY ROCK & RECYCLING ROUTINELY EXERCISES THEIR RIGHT TO SEND MATERIALMAN'S NOTICES TO ALL JOBS. 3. TAXES. All federal, state and local taxes, assessments, fees, duties and charges levied by reason of this Proposal are in addition to prices quoted herein and shall be paid by Purchaser. 4. DELIVERY CONDITIONS. Signed Purchaser has requested Kangley Rock & Recycling, a Division of Gary Merlino Construction Company, Inc. (Seller) to make use of a path for the delivery of materials and access to the project requiring trucks to travel beyond the boundaries of the nearest traveled public highway. Seller has advised that due to the size and weight of trucks, damage to the premises and/or adjacent property, or personal injury may occur and that trucks may become damaged, disabled or stuck if Seller makes use of the path requested. Seller has further advised that it is their policy that deliveries requiring Seller's trucks travel beyond the nearest highway to obtain access to the job site are at the risk of the Purchaser, and that Seller assumes no liability for property damage or personal injury that may result. Purchaser agrees to assume responsibility to Seiler and third parties for property damage, personal injuries, truck towing and winching expenses, and/or damage to Seller's trucks should the trucks become damaged, disabled or stuck as a result of Seller making use of the path requested or for the delivery of materials and access to the project site. Purchaser also agrees to indemnify, hold harmless. and defend Seller from any claims, demands, losses, and liabilities to or by third parties arising from, resulting from, or connected with the use of the requested path for the delivery of materials whether such claims may prove to be true or false, groundless or fraudulent. to the full extent permitted by law and subject 16 the limitations below. Purchaser's duty to indemnify Seller for liability for damages arising out of bodily injury to persons or damage to property caused by or resulting from the concurrent negligence of (a) Kangley Rock & Recycling, a Division of Gary Merlino Construction Company, Inc. or its agents and employees, and (b) the Purchaser shall apply only to the extent of the negligence of the Purchaser or its agents and employees. For the purpose of the Purchaser's indemnification obligation only, the Purchaser specifically and expressly waives any immunity that may be granted it under the Washington State Industrial Insurance Act. Title 51 RCW. This waiver does not permit a direct action by the Purchaser's employees against the Purchaser. Further, the indemnification obligation under this Agreement shall not be limited in any way by any limitation on the amount or type of damages, compensation or benefits payable to or for any third party under worker's compensation acts, disability benefit acts, or their employee benefit acts. This promise of indemnity specifically applies r the case of injuries to the undersigned's own employees. The undersigned s duty to defend: indemnify and hold Seller harmless shall include, as to all claims, demands, losses, and liability to which it applies, Seller's personnel related costs, reasonable attorney's fees, court costs, and all other claim -related expenses, including attorney's fees and other costs incurred by Seller to Enforce and_establish_ its right under this Agreement. Upon Seller's tender of defense under this Agreement, the Purchaser agrees to appoint counsel of Seller's choice to defend against third party claim(s). Such counsel will be at the sole expense of the Purchaser. Seller is not responsible for means and methods of placement of ready mixed concrete or aggregate products on a project. 5. LIMITATION ON DAMAGES. Seller assumes no responsibility for, and shall not be liable to. Purchaser for any consequential damages incurred by Purchaser in connection with this Contract, including without limitation, Purchaser's lost profits, Purchaser's good will, and any injury to person or property proximately resulting frorn any breach by Seller or breach of warranty by Seller. 6. CLAIMS AND BACK CHARGES. Purchaser's exclusive procedure for commencing claims under this Contract against Seller for any reason. including breach of contract or breach of warranty, shall be as follows: Notice of claims against Seller for any reason. including but not limited to, breach of contract or warranty, must be given to Seller in writing within three (3) working days after discovery or when discovery should have been made. The written claim shall include the reason(s) and grounds for the claim and the dollar amount or relief sought. FAILURE OF PURCHASER TO GIVE SUCH NOTICE bNITHIN THREE (3) WORKING DAYS SHALL CONSTITUTE A WAIVER BY PURCHASER OF ITS RIGHT TO LATER MAKE ANY SUCH CLAIM. If a dispute arises and cannot be resolved, the parties involved agree to binding arbitration through non -legal personnel. 7. TITLE AND RISK OF LOSS. Unless otherwise expressly stated herein, title to the materials sold hereunder shall remain with Seller until Seller has received full payment for the same. Risk of loss of the materials sold under this Contract shall pass to the Purchaser upon delivery of the same, at the place of delivery designated herein. Thereafter. in addition to assuming all risk of loss, Purchaser shall be responsible for compliance with all governmental regulations and ordinances with regard to storage or placement of the same and shall indemnify and hold Seller harmless against all claims for personal injuries, including death. and property damage arising from the storage, use or handling of said materials. ��Ot1 C 0/yC�t� Ix rn YCL�'i 6/ABILITY G�� r-� 1 Date: Customer: RENTON CONCRETE RECYCLERS 22121 17th Ave S.E. Suite #117 Bothell, WA 98021 Pit Site: 500 Monster Road S.W. Renton, WA Business Office: 425-481-9101 Scale House: 206-772-2278 ly t4IJ2 Ticket # Project Name/P.O. Number: rD Project Location (City, Street): 's 1 Trucking Company: ❑ Cash Scaleperson: Account Truck# Time Material Gross Weight Tare Weight Mate alish a Net Tons/Yd3 Price TERMS: NET 30 DAYS FROM END OF MONTH. A Finance Charge will e assessed on all past due accounts at a rate of 1 112% per month. Total Material Annual finance charge of 18% NOTICE: It is specifically agreed that this company shall not 5%Environmental Fee be in anyway responsibye for damage to customers property Sales Tax resutling from deliveries beyond the curb line. Total DRIVER SIGNATURE/PRINTED NAME: Concrete: Injurious to eyes.Causes skin imtation.Contains Portland Cement. Read the following warning before using: Contact with wet, unhardened concrete, mortar, cement or cement matures can cause skin irritation, severe chemical bums or serious eye damage. Avoid contact with eyes and skin. Wear waterproof gloves, a fully -buttoned, long -sleeve shirt fulHergth trousers and fight -fitting eye protection when working with these materials. If you have to stand in wet concrete, use waterproof boots that are tight at the top and high enough to keep concrete from flowing into them. If finishing concrete, wear knee pads to protect knees. After contact with any of these materials, wash off immediately with fresh. dean water. Indirect contact through clothing is as dangerous so promptly rinse these materials from clothing. Seek immediate medical attention if you have persistent or severe disaxr#ort.ln case of eye contact flush with plenty of water for at least 15 minutes. Consult physician immediately. KEEP out of reach of children! User agrees to convey this warning to all persons who may use or come into contact with wet (unhardened) concrete, mortar, cement or cement mixtures. Aggregates: Prolonged inhalations of dust from a gravel product may be hazardous to your health. Measures to control fugitive dust should be taken when handling this product. Hot Asphalt en-& nuisance fumes. Avoid breathing fumes. Also, Asphalt may case severe bums. Wear protective safety gear (long sleeves, pants and gloves). If burned, cool with water and see a physician. Water added at customer's own risk. Additional water added to concrete will Property Damage Indemnification & Release reduce its strength.Buyer's agent agrees to accept responsibility for reduced strength The operator of this piece of heavy equipment, in presenting this RE - due to water added above design. LEASE to you for your signature, is of the opinion that the operation of this machinery in the manner required to perform our contract with you may Arrived at job with inch slump. El possby cause damage to the premises or property. It is our wish to heap you it everyway that we can. but in order to do this, the operator is asking Added gal water at customer request. Test cylinders that you sign this RELEASE. In consideration of the performance of the taken seller of its contract with me, I the undersigned, hereby INDEMNIFY the Other additions seller and its employees for any damage and for all claims to the premises, r �J building. utility pipelines or cables. telephone lines, driveway or other Received ! I c/ appurtenances, at: by Buyer's Agent receipt of product and approval of any added items The addition of any extra products to our mixer may void any warranty expressed or implied by the seller. The seller accepts no liability for any personal injury incurred by you while adding additional products to our mixer. and RELEASE the seller and its employees from any liability. Signature of Owner or its Agent Sign ature ure of Owner or its Agent WGDELTKT090.40$ Leave Plant Arrive Job Sit Start Discharg Finish Dlschargel Leave Job Site Arrive Plant Drivers' Comments Company/ Customer PO/ Order No. Cust. No. Customer Job Phase Code Customer i `_>c_' r Delivery Address Delivery Instructions I T i F F_ �` C:r� r� r r lt� P/ I t SEfI l 1 i F TICKETNO. Load Qty Delivered Qty Order Qty ProductCode UOM Product Description 3. 0 a J�C� Gross Tare Trk 30140 24140 Trlr. 1 <<_ 1 t o MOD f f= t E_D CL.CASS B Net 6000 FUEL_ CHID CUSTONIEH/OFFICE 3606333 Unloading & Standby Excess unloading will be charged at posted truck time rates. Truck standby time charged at posted truck time rates. Limited Warranty The only liability of the seller for product defect is the return of the purchase price. In no event shall the seller be liable for any direct, indirect, incidental or consequential damages resulting from the use of the products or arising out of breach of any warranty. All claims for damages or shortages must be made within 24 hours of delivery.We do not assume responsibility for any damage beyond the curb line. ICON MATERIALS 1115 SOUTH 96TH SEATTLE, WA 98106 21016-7E7-2521 Driver Co. Proj. No. OUTSft_ L1i< l0ap 0-i Zone UnitPrice Amount Lciad;gjiiCf "PFdd.' Ko; DeRription C / N ; Slump Type CC Use Haul Cd. Pit/Plant Sales Tax TOTAL DUE L At7j, 4 in Truck Gross Weight Tare Weight Trailer Trailer Taken by Check r_r•r_r_r.r_�r_r.r_r.r_�r_r_r_r_r•a.a.r•r•r_r_�r.r•��r_ ��r_ w Concrete: Injurious to eyes.Causes skin irritation.Contains Portland Cement. Read the following warning before using: Contact with wet, unhardened concrete. mortar, cement or cement mixtures can cause skin irritation, severe chemical bums or serious eye damage. Avoid contact with eyes and skin. Wear waterproof gloves, a fully -buttoned, long -sleeve shirt, fulHergth trousers and tight -fitting eye protection when working with these materials. If you have to stand in wet concrete, use waterproof boots that are tight at the top and high enough to keep concrete from flawing into them. If finishing concrete, wear knee pads to prated knees. After contact with any of these materials. wash off immediately with fresh, dean water. Indirect contact through clothing is as dangerous so promptly rinse these materials from dothirig. Seek immediate medical attention if you have persistent or severe discornfort.ln case of eye contact, flush with plenty of water for at least 15 minutes. Consult physician immediately. KEEP out of reach of children! User agrees to convey this warning to all persons who may use or come into contact with wet (unhardened) concrete, mortar, cement or cement mixtures. Aggregates: Prolonged inhalations of dust from a gravel product may be hazardous to your heath. Measures to control fugitive dust should be taken when handling this product Hot Asphalt emits nuisance fumes. Avoid breathing fumes. Also, Asphalt may cause severe bums. Wear protective safety gear (long sleeves, pants and gloves). If burned, cool with weer and see a physician. Water added at customer's own risk. Additional water added to concrete will Property Damage Indemnification & Release reduce its strength.Buye(s agent agrees to accept responsibility for reduced strength The operator of this piece of heavy equipment in presenting this RE - due to water added above design. LEASE to you for your signature, is of the opinion that the operation of this with inch slump. machinery in the manner required to perform our contract with you may Arrived at l p � possibly cause damage to the premises or property. It is our wish to help you in everyway that we can, but in order to do this, the operator is asking Added gal water at customer request. Test cylinders that you sign this RELEASE. In consideration of the perfortTance of the taken seller of its contract with me, I the undersigned. hereby INDEMNIFY the Other additions seller and its employees for any damage and for all daims to the premises, building, utility pipelines or cables, telephone lines, driveway or other Received % j, �_:. appurtenances, at: by X f Buyer's Agent receipt of product and approval of any abed items. and RELEASE the seller and its employees from The addition of an extra roducts to our mixer ma void a warren an liability CUSTOMER/OFFICE 3606329 Unloading & Standby Excess unloading will be charged at posted truck time rates. Truck standby time charged at posted truck time rates. Limited Warranty The only liability of the seller for product defect is the return of the purchase price. In no event shall the seller be liable for any direct, indirect, incidental or consequential damages resulting from the use of the products or arising out of breach of any warranty. All claims for damages or shortages must be made within 24 hours of delivery.We do not assume responsibility for any damage beyond the curb line. Y P Y m tY Y ICON MATERIALS expressed or implied by the seller. The seller accepts no liability for any personal injury incurred by you while adding additional products to our 1115 SOUTH 96TH mixer. Signature of Owner or its Agent sEA-rTlrE WA 9810e Signature of Owner or its Agent Leave Plant Arrive. Job Site Start Disch Drivers' Comments Order No. Cust. No Customer 47.5 —_— NWGDELTKTO90404 Finish Discharge Leave Job Site Arrive Plant Company/ Customer PO/ Customer Job Phase Code Delivery Address Delivery Instructions lTIES EXCAVATING P/U SEATTLE TICKET NO. J.:i 1 oL,569 206-767— 2521 Driver Cm Proj. No. O L_I-i Date i 1 ft Map 0 ! Zone: Scale Time: !tY Delivered Oty OrderQty ProductCode UOM Product Description - = UnitPrice 3.50 -_. 50 1 (`1 fi"i "i�lj;'1' .-_i':1.._Fi `�._ t.:• .. . 13r,0 s _ Tare Net Tr,k> 1.140 �:4140 7000 frl.r_ FUEL.. CCHO Load Size Prod, No., Desfription f_ �N 7 Slump Type CC Use Haul Cd. Pit/Plant Sales Tax TOTAL DUE Truck Gross Weight Tare Weight Trailer Trailer Checks # ICON Materials Correspondence address: Please remit payment to: 1508 Valentine Ave SE ICON Materials Pacific WA 98047 PO Box 742421 206-575-3200 Los Angeles CA 90074 Account No: 47527 B & B Utilities & Excavating L 23431 45th Ave SE Bothell WA 98021 Page: Invoice Number: 50- 1717414 Invoice Date: 07/19/2012 Customer Job: Customer P0: 1230 Ship Address: P/U SEATTLE 1 maienai units uvm Unit Price Invoice Totals Date: 7119112 Proaucz Use. "JSDOT Class B --e S,:,Cha,ge - EA Ticket Numbers: 6.00 TON 81.50 6.00 EA 0.35 Total For 7/19/12 Invoice Totals 489.00 2.10 491.10 $491.10 Thank You! We appreciate your business. Account is due in full on the 10th of the month following purchases. A LATE charge of 1 112 % per month, which is an annual percentage rate of 18 % or $ 2.00 whichever is greater, will be charged on all accounts not paid by the 25th of the month following purchases. . Depand lnallstlie CERTIFIED PAYROLL REPORT Prevail mi g W Wage Program ' ing Wage Program "4 PO Box 44540 2 Project Name county Project or Contract# Olympia WA 98504-4540 "wy� R� ay Prime Contractor ® SE 5TH AC WATER MAIN King CAG-12-056 (360) 902-5335 REPLACEMENT Subcontractor Project Address City State SE 5TH RENTON WA Awarding Agency Name Phone Company Name Phone For the week ending: CITY OF RENTON 425-430-6510 B&B Utilities and Excavating, LLC 425-398-5906 Month Day Year Address City State ZIP+4 Address City State ZH3+4 07/14/2012 1055 S GRADY WAY RENTON WA 98055 23431 45' Ave SE Bothell WA 98021 Day and Date Deductions Work Classification Name d Sun Mon Tue Wed Thu Fri Sat Total and and v Rate Hourly Soc Sec# of Employee Address x 7�9/12 7/10/12 7/11/12 7/12/12 7/13/12 7/1N12 Total of Gross Amount "Usual With NET Hours Worked Each Da Hours Pa Earned Benefits" FICA Tax Other WAGES 1. Laborer Adam Hampton OT 0.50 0.50 1.00 60.05 60.05 700.53 S 0.00 $39.58 $90.71 $9.16 $561.08 RG 9.00 8.00 16.00 40.03 640.48 2. Dump Truck Jack Butcher OT 0.00 0.00 0.00 $ 0.00 $ 0.00 RG 0.00 0.00 3. Operator Matt Coulson OT 0.00 0.00 0.00 s 0.00 $ 0.00 RG 0.00 0.00 4. Laborer Scott Crocker OT 0.50 0.50 1.00 60.05 60.05 920.70 $ 0.00 $52.01 597.10 510.95 $760.64 RG 2.50 3.00 8.00 8.00 21.50 40.03 860.65 5 OT 0.00 0.00 0.00 s 0.00 $ 0.00 RG 0.00 0.00 6 OT 0.00 0.00 0.00 a 0.00 s 0.00 RG 0.00 0.00 7 OT 0.00 0.00 0.00 $ 0.00 $ 0.00 RG 0.00 0.00 8 OT 0.00 0.00 0.00 a 0.00 a 0.00 RG 0.00 0.00 9. OT 0.00 0.00 0.00 s 0.00 $ 0.00 RG 0.00 0.00 10. OT 0.00 0.00 0.00 $ 0.00 s 0.00 RG 0.00 0.00 F700-065-000 certified payroll report 05-09 Employee Benefits Distribution and Signature Certification on Reverse Side Department of Labor and Industries Prevailing Wage Program PO Box 44540 Olympia WA 98504-4540 AFFIRMATION Today's Date Printed name of party signing this report Title 08/01/2012 Maulitta Brown Office Manager The party signing this report pays or supervises the (Name of contractor or subcontractor) payment of the persons employed by: B&B Utilities and Excavating, LLC Project Name: For the week starting: For the week ending: SE 5TH ST AC WATER MAIN REPLACEMENT 07/12/12 07/14/12 "USUAL BENEFITS" DISTRIBUTION (Please report in "per hour" terms) Work Classification Total Hourly "Usual Benefits" (A+B+C+D+E) (A) Hourly Pension (B) Hourly Medical (C) Hourly Vacation (D) Hourly Holiday (E) Approved Apprentice Program PP g 1. Laborer $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2.Dump Truck $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3.0perator $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4.Laborer $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5. $ 0.00 6. $ 0.00 7. $ 0.00 8. $ 0.00 9. $ 0.00 10. $ 0.00 The party signing below AFFIRMS the following: (1) All information contained in this Certified Payroll Report, including any addenda, is correct and complete. (2) The wage rates for workers, laborers or mechanics as reported above are not less than the applicable wage rates contained in any wage determination related to the contract; and the classifications as reported above for each worker, laborer or mechanic conform with the actual work performed by such worker, laborer or mechanic. (3) The payments of usual benefits as listed above have been or will be made to appropriate approved plans, funds or programs for the benefit of such employees. (4) All persons employed on the above -referenced project(s) have been paid the full weekly wages earned, and no rebates have been or will be made either directly or indirectly to or on behalf of the above -named contractor or subcontractor from the weekly wages earned by any person. No deductions, other than those which are legally permissible, have been made by any person either directly or indirectly from the full wages earned. (5) Any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with the Washington State Apprenticeship and Training Council. Falsification of any of the above statements is a violation of RCW 39.12.050 subject to prosecution; �antton'I, and penalties. / II (( Print or type name of party signing this report Title S�Tat4 Maulitta Brown Office Manager I / V Y//X� F700-065-000 certified payroll report backer 05-09 11M • Depailing Wageogra Industries �Eya7. Prevailing Wage Program y 4" CERTIFIED PAYROLL REPORT PO Box 44540 Olympia WA 985044540 (360) 902-5335 = yy � ,R� Prime Contractor ® Project Name SE 5TH AC WATER MAIN REPLACEMENT Cwill k King Project or Contract# CAG-12-056 Subcontractor Project Address SE 5TH City RENTON State WA Awarding Agency Name Phone Company Name Phone For the week ending: CITY OF RENTON 425-430-6510 B&B Utilities and Excavating, LLC 425-398-5906 Month Day Year Address City State ZIP+4 Address City State ZIP+4 7/21/12 1055 S GRADY WAY RENTON WA 98055 23431 45' Ave SE Bothell WA 98021 Day and Date Deductions Work Classification and Soc Sec# of Employee Name and Address d x Sun Mon Tue Wed Thu Fri Sat Total Rate of Gross Amount Total Hourly "Usual NET Withold- 7nb �z vn,1z 7nariz 7nw1z 7nalz 7nvls Hours Worked Each Day Hours Pay Earned Benefits" FICA ing Tax Ocher WAGES 1. Laborer Adam Hampton OT 0.00 60.05 0.00 1120.84 $ 0.00 s65.41 s235.86 s9.99 $so9.69 RG 9.00 10.00 9.00 0.00 0.00 28.00 40.03 1120.94 2. Dump Truck Jack Butcher OT 0.00 0.00 276.79 $ 0.00 $15.63 $38.54 $2.96 $ 219.65 RG 3.00 3.00 6.00 46.13 276.78 3. Operator Masi COUl80II OT 0.00 0.00 1385.44 $ 0.00 79.11 202.16 II.LO 51,093.07 RG 9.00 10.00 9.00 28.00 49.48 1395.44 4. Laborer Scott Crocker OT OT 0.00 60.05 0.00 S 0.00 $88.55 $230.53 $12.73 51,189.33 RG 9.00 10.00 9.00 10.00 38.00 40.03 1521.14 5 OT 0.00 0.00 0.00 $ 0.00 a 0.00 -- RG 0.00 0.00 6 OT 0.00 0.00 0.00 s 0.00 $ 0.00 RG 0.00 0.00 7 OT 0.00 0.00 0.00 $ 0.00 $ 0.00 RG 0.00 0.00 8 OT 0.00 0.00 0.00 s 0.00 $ 0.00 RG 0.00 0.00 9 OT 0.00 0.00 0.00 s 0.00 s 0.00 RG 0.00 0.00 10. OT 0.00 0.00 0.00 $ 0.00 $ 0.00 RG 0.00 0.00 F700-065-000 certified payroll report 05-09 Employee Benefits Distribution and Signature Certification on Reverse Side Department of Labor and Industries Prevailing Wage Program PO Box 44540 Olympia WA 98504-4540 AFFIRMATION Today's Date Printed name of party signing this report Title 08/01/2012 Maulitta Brown I Office Manager The party signing this report pays or supervises the (Name of contractor or subcontractor) payment of the persons employed by: B&B Utilities and Excavating, LLC Project Name: For the week starting: For the week ending: SE 5TH ST AC WATER MAIN REPLACEMENT 07/16/12 07/21/12 "USUAL BENEFITS" DISTRIBUTION (Please report in "per hour" terms) Work Classification Total Hourly "Usual Benefits" (A + B + C + D + E) (A) Hourly Pension (B) Hourly Medical (C) Hourly Vacation (D) Hourly Holiday (E) Approved Apprentice Program 1. Laborer $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2.Dump Truck $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3.0perator $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4.Laborer $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5. $ 0.00 6. $ 0.00 7. $ 0.00 8. $ 0.00 9. $ 0.00 10. $ 0.00 The party signing below AFFIRMS the following: (1) All information contained in this Certified Payroll Report, including any addenda, is correct and complete. (2) The wage rates for workers, laborers or mechanics as reported above are not less than the applicable wage rates contained in any wage determination related to the contract; and the classifications as reported above for each worker, laborer or mechanic conform with the actual work performed by such worker, laborer or mechanic. (3) The payments of usual benefits as listed above have been or will be made to appropriate approved plans, funds or programs for the benefit of such employees. (4) All persons employed on the above -referenced project(s) have been paid the full weekly wages earned, and no rebates have been or will be made either directly or indirectly to or on behalf of the above -named contractor or subcontractor from the weekly wages earned by any person. No deductions, other than those which are legally permissible, have been made by any person either directly or indirectly from the full wages earned. (5) Any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with the Washington State Apprenticeship and Training Council. Falsification of any of the above statements is a violation of RCW 39.12.050 subject to prosecution, anc ions, andpenalties. r /�\ I A Print or type name of party signing this report Title S g tture Maulitta Brown Office Manager F700-065-000 certified payroll report backer 05-09 Department of Labor and Industries .1•, A 7.,, J Prevailing Wage Program y, CERTIFIED PAYROLL REPORT PU Box 44540 = Project Name l Ixult� Project or Contract# Olympia WA 98504-4540 �y y Prime Contractor ® ` 'dam " SE 5TH AC WATER MAIN King CAG-12-056 (360) 902-5335 REPLACEMENT Project Address City State Subcontractor SE 5TH RENTON WA Awarding Agency Name Phone Company Name Phone For the week ending: CITY OF RENTON 425-430-6510 B&B Utilities and Excavating, LLC 425-398-5906 Month Day Year Address City State ZIP+4 Address City State ZIP+4 7/28/12 1055 S GRADY WAY RENTON WA 98055 23431 45a' Ave SE Bothell WA 98021 Day and Date Deductions Work Classification Name � Sun Mon Tue Wed Thu Fri Sat Total and and -E t Rate Hourly Soc Sec# of Employee Address x 7/2N12 1 7/24112 1 7125/12 7/26112 7/27/12 7/2&12 Total of Gross Amount "Usual Withold- NET Hours Worked Each Day Hours Pay Earned Benefits" FICA ing Tax Other WAGES 1. Laborer Adam Hampton OT 3.50 3.50 60.05 210.18 1571.20 $ 0.00 $86.71 $312.66 $13.10 $1,158.73 RG 11.50 9.50 8.50 5.50 34.00 40.03 1361.02 2. Dump Truck Jack Butcher OT 0.00 0.00 92.26 $ 0.00 s5.21 s12.84 s0.98 S 73.23 RG 2.00 2.00 46.13 92.26 3.Operator Matt Coulson OT 0.50 0.50 74.23 37.12 432.96 $ 0.00 23.63 60.38 3.32 $345.63 RG 8.00 8.00 49.48 395.84 4. Laborer Scott Crocker OT OT 6.00 6.00 60.05 360.30 $ 0.00 $108.22 $281.75 $15.55 $1,555.98 RG 11.50 8.50 8.50 9.30 3.00 40.00 40.03 1601.20 5 OT 0.00 0.00 0.00 $ 0.00 $ 0.00 RG 0.00 0.00 6 OT 0.00 0.00 0.00 a 0.00 $ 0.00 RG 0.00 0.00 7 OT 0.00 0.00 0.0o s 0.00 $ 0.00 RG 0.00 0.00 8 OT 0.00 0.00 0.00 s 0.00 a 0.00 RG 0.00 0.00 9 OT 0.00 0.00 0.00 $ 0.00 $ 0.00 RG 0.00 0.00 10. OT 0.00 0.00 0.00 $ 0.00 s 0.00 RG 0.00 0.00 F700-065-000 certified payroll report 05-09 Finp/upee Benefits Distribution and .Signature Certification on Reverse .Vitle Department of Labor and Industries Prevailing Wage Program PO Box 44540 Olympia WA 98504-4540 AFFIRMATION Today's Date Printed name of party signing this report Title 08/01/2012 Maulitta Brown Office Manager The party signing this report pays or supervises the (Name of contractor or subcontractor) payment of the persons employed by: B&B Utilities and Excavating, LLC Project Name: For the week starting: For the week ending: SE 5TH ST AC WATER MAIN REPLACEMENT 07/23/12 07/28/12 "USUAL BENEFITS" DISTRIBUTION (Please report in "per hour" terms) Work Classification Total Hourly "Usual Benefits" (A+B+C+D+E) (A) Hourly Pension (B) Hourly Medical (C) Hourly Vacation (D) Hourly Holiday (E) Approved Apprentice Program 1. Laborer $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2.Dump Truck $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3.0perator $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4.Laborer $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5. $ 0.00 6. $ 0.00 7. $ 0.00 8. $ 0.00 9. $ 0.00 10. $ 0.00 The party signing below A FF I RMS the following: (1) All information contained in this Certified Payroll Report, including any addenda, is correct and complete. (2) The wage rates for workers, laborers or mechanics as reported above are not less than the applicable wage rates contained in any wage determination related to the contract; and the classifications as reported above for each worker, laborer or mechanic conform with the actual work performed by such worker, laborer or mechanic. (3) The payments of usual benefits as listed above have been or will be made to appropriate approved plans, funds or programs for the benefit of such employees. (4) All persons employed on the above -referenced project(s) have been paid the full weekly wages earned, and no rebates have been or will be made either directly or indirectly to or on behalf of the above -named contractor or subcontractor from the weekly wages earned by any person. No deductions, other than those which are legally permissible, have been made by any person either directly or indirectly from the full wages earned. (5) Any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with the Washington State Apprenticeship and Training Council. Falsification of any of the above statements is a violation of RCW 39.12.050 subject to Print or type name of party signing this report I Title g � ratT I /I Maulitta Brown Office Manager ` and penalties. F700-065-000 certified payroll report backer 05-09 Department of Labor and Industries �� sTA�� Employment Standards Program ,� ,� PO Box 44510 x Olympia WA 98504-4510 �, �� (360) 902-5316 6'` '""� N Awarding Agency Name For the week ending: City of Renton Month Day Year Address 7 / 14 / 12 1055 S. Gradv Way Prime Contractor Subcontractor Cite Renton CERTIFIED PROJECT PAYROLL 'roject Name County Project or Contract# SE 5th St AC Water Main Replace. King CAG-12-056 'roject Address City State Renton WA Phone Company Name Salinas Sawing & Sealing, Inc. state ZIP+4 Address WA 98055 7804 40th Ave W. City Mukilteo Phone (425)745-0706 State ZIP+4 WA 98275 Work Classification and Soc Sec# of Employee Name and Address v W to o a Day and Date Sun Mon Tue Wed Thu Fri Sat Total Hours Rate of Pay Gross Amount Earned Deductions NET WAGES FICA Withhold -ing Tax Other 8 s 10 �� 12 is 14 Hours Worked Each Day GROUP 4 LABORER CSO 3212 BARRY J. HUMES 23711 42ND AVE SE #41A BOTHELL, WA 98012 OT 0.00 0.00 $ 190.20 143.68 575.00 262.02 $ 1,562.31 RG 6.00 6.00 31.70 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 $ 0.00 $ RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 0.00 RG 0.00 F700-065-000 certified project payroll 10-01 Empiovee Benefits Distribution and Signature Certification on Reverse Department of Labor and Industries Employment Standards Program PO Box 44510 Olympia WA 98504-4510 (1) AFFIRMATION Today's Date Name of signatory party Title 07/20/2012 1 Andrea Poua Administrative Assistant The above signatory pays or supervises (Name of contractor or subcontractor) the payment of the persons employed by: Salinas Sawing & Sealing, Inc. Name of building or work protect Payroll period starting Payroll period ending SE 5th St AC Water Main Replacement 07/08/2012 07/14/2012 All persons employed on above project have been paid the full weekly wages earned, that no rebates have/will be made either directly or indirectly to or on behalf of the above contractor or subcontractor from the weekly wages earned by any person and that no deduction have been made either directly or indirectly from the full wages earned by any person, other than permissible deduction. (2) That any payroll otherwise inder this contract required to be submitted for the above period are correct and complete, that the wage rates for laborers or mechanics contained therein are not less then the applicable wage rates contained in any wage determination incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conforms with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency. That: (4) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS " In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed below have been or will be made to appropriate programs for the benefits of such employees. The willful falsification of any of the above statements may subject the contractor to civil or criminal prosecution. Print or type name of signatory Title Signature Andrea Poua Administrative Assistant I ( BENEFIT DISTRIBUTION (Please report in "per hour" terms) Craft/Trade Hourly Total Benefit Credit Hourly Pension Hourly Medical Hourly Vacation LECET / TRAIN LABORERS 9.52 3.70 5.30 0.52 F700-065 backer 10-01 • �t Department of Labor and Industries _�, , Prevailing Wage Program �:,`� CERTIFIED PAYROLL REPORT ry nox "i,#V Project Name County Project or Contract# Olympia WA 985044540 �9 ` ��y Prime Contractor ® a SE 5TH AC WATER MAIN King CAG-12-056 (360) 902-5335 �8B' REPLACEMENT Subcontractor OA-- Project Address City State SE 5TH RENTON WA Awarding Agency Name Phone Company Name Phone For the week ending: CITY OF RENTON 425-430-6510 B&B Utilities and Excavating, LLC 425-398-5906 Month Day Year Address City State ZIP+4 Address City State ZIP+4 8/4/12 1055 S GRADY WAY RENTON WA 98055 23431 45 h Ave SE Bothell WA 98021 Day and Date Deductions Work Classification Name m a Sun Mon Tue Wed Thu Fri Sat and and Rate Total Hourly Soc Sec# of Employee Address I 7na1z 713tnx e/tilz 8rv1z -12 aratz Total of Gross Amount "Usual Withold- NET Hours Worked Each Day Hours Pay Eamed Benefits" FICA ing Tax Other WAGES 1. Laborer Adam Hampton OT 1.00 3.00 4.00 60.05 240.20 1521.16 $ 0.00 $87.39 S323.47 $13.04 S1,097.26 RG 8.00 8.00 8.00 9.00 32.00 40.03 1280.96 2. Dump Truck Jack Butcher OT 0.00 0.00 322.91 $ 0.00 s10.52 s26.05 st.tl s2e5.23 RG 1.00 4.00 2.00 7.00 46.13 322.91 3.Operator Matt Coulson OT 3.00 3.00 74.23 222.69 1410.21 $ 0.00 81.24 241.32 10.11 $1,077.54 RG 9.00 8.00 8.00 24.00 49.48 1187.52 4. Laborer Scott Crocker OT 1.00 3.00 4.00 60.05 240.20 1521.16 S 0.00 $83.95 S159.31 $11.94 $1,263.96 RG 8.00 9.00 8.00 9.00 32.00 40.03 1280.96 5. Laborer Zach Dittenber OT 3.00 3.00 0.00 0.00 $ 0.00 s66.26 s189.76 $10.45 s- 26s.a7 RG 9.00 9.00 9.00 24.00 0.00 6 OT 0.00 0.00 0.00 $ 0.00 $ 0.00 RG 0.00 0.00 7. OT 0.00 0.00 0.00 $ 0.00 s 0.00 RG 0.00 0.00 8 OT 0.00 0.00 0.00 $ 0.00 s 0.00 RG 0.00 0.00 9. OT 0.00 0.00 0.00 $ 0.00 s 0.00 RG 0.00 0.00 10. OT o.ao 0.01 0.00 $ 0.00 s 0.00 RG o.o0 0.00 F700-065-000 certified payroll report 05-09 Employee Benefits Distribution and .Vignature Certification on Reverse Side DepartrAnt of Labor and Industries Prevailing Wage Program PO Box 44540 Olympia WA 98504-4540 AFFIRMATION Today's Date Printed name of party signing this report Title 08/17/2012 Maulitta Brown Office Manager The party signing this report pays or supervises the (Name of contractor or subcontractor) payment of the persons employed by: B&B Utilities and Excavating, LLC Project Name: For the week starting: For the week ending: SE 5TH ST AC WATER MAIN REPLACEMENT 07/30/12 08/03/12 "USUAL BENEFITS" DISTRIBUTION (Please report in "per hour" terms) Work Classification Total Hourly "Usual Benefits" (A+B+C+D+E) (A) Hourly Pension (B) Hourly Medical (C) Hourly Vacation (D) Hourly Holiday (E) Approved Apprentice Program 1. Laborer $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2.Dump Truck $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3.0perator $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4.Laborer $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5.Laborer $ 0.00 6. $ 0.00 7. $ 0.00 8. $ 0.00 9. $ 0.00 10. $ 0.00 The party signing below AFFIRMS the following: (1) All information contained in this Certified Payroll Report, including any addenda, is correct and complete. (2) The wage rates for workers, laborers or mechanics as reported above are not less than the applicable wage rates contained in any wage determination related to the contract; and the classifications as reported above for each worker, laborer or mechanic conform with the actual work performed by such worker, laborer or mechanic. (3) The payments of usual benefits as listed above have been or will be made to appropriate approved plans, funds or programs for the benefit of such employees. (4) All persons employed on the above -referenced project(s) have been paid the full weekly wages earned, and no rebates have been or will be made either directly or indirectly to or on behalf of the above -named contractor or subcontractor from the weekly wages earned by any person. No deductions, other than those which are legally permissible, have been made by any person either directly or indirectly from the full wages earned. (5) Any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with the Washington State Apprenticeship and Training Council. Falsification of any of the above statements is a violation of RCW 39.12.050 subject to p nctions, and penalties. Print or type name of party signing this report Title I rtat Maulitta Brown Office Manager WJ F700-065-000 certified payroll report backer 05-09 r and Depart ent of Industries �gTATF °^q CERTIFIED PAYROLL REPORT Prevait��,gWageabogram Prevailing Wage Program �"� PO Box 44540 - Project Name County Project or Contract# Olympia WA 98504-4540�R a�y� Prime Contractor ® SE 5TH AC WATER MAIN King CAG-12-056 (360) 902-5335 REPLACEMENT Subcontractor Project Address city State SE 5TH RENTON WA Awarding Agency Name Phone Company Name Phone For the week ending: CITY OF RENTON 425-430-6510 B&B Utilities and Excavating, LLC 425-398-5906 Month Day Year Address City State ZIP+4 Address City State ZIP+4 8/17/12 1055 S GRADY WAY RENTON WA 98055 23431 45th Ave SE Bothell WA 98021 Day and Date Deductions Work Classification Name 6 Sun Mon Tue Wed Thu Fri Sat Total 1 1 1 1 and and Rate Hourly Soc Sec# of Employee Address a 8i4/12 eronz 8B/12 819n2 a10112 9/11/12 Total of Gross Amount "Usual Withold- NET Hours Worked Each Day Hours Pay Earned Benefits" FICA ing Tax Other WAGES 1. Laborer Adam Hampton OT 2.00 zoo 3.00 7.00 60.05 420.35 1701.31 $ 0.00 $94.68 5350.43 S14.12 51,242.08 RG 8.00 9.00 9.00 8.00 3200 40.03 1290.96 2. Dump Truck Jack Butcher OT 0.00 0.00 253.72 $ 0.00 s7.80 s18.96 s0.80 $226.26 RG 3.50 2.00 5.50 46.13 253.72 3. Operator Matt Coulson OT 2.00 2.50 3.00 7.50 74.23 556.73 2140.09 $ 0.00 119.35 354.52 14.85 $1,651.37 RG 8.00 8.00 8.00 8.00 32.00 49.48 1593.36 4. Laborer Z8Ch Dittenber OT 2.00 2.00 3.00 7.00 60.05 420.35 1381.07 $ 0.00 $76.24 $217.17 $12.02 51,075.64 RG 8.00 8.00 9.00 24.00 40.03 960.72 5. Laborer James Pigott OT 2.00 2.50 3.00 7.50 0.00 0.00 $ 0.00 T79.73 $158.36 $13.15 5-251.24 RG 8.00 9.00 9.00 24.00 0.00 6. Laborer Kevin Pownall OT 2.00 2.50 3.00 7.30 0.00 0.00 $ 0.00 s97.93 $0.00 S12.77 s ll0.60 RG 9.00 8.00 8.00 8.00 32.00 0.00 7. OT 0.00 0.00 0.00 S 0.00 $ 0.00 RG 0.00 0.00 8 OT 0.00 0.00 0.00 a 0.00 $ 0.00 RG 0.00 0.00 9 OT 0.00 0.00 0.00 S 0.00 $ 0.00 RG 0.00 0.00 10. OT 0.00 0.00 0.00 $ o.00 $ 0.00 RG 0.00 0.00 F700-065-000 certified payroll report 05-09 Empkgee Renefity Distribution and ,Vignature Certification on Reverse Side Department of Labor and Industries Prevailing Wage Program PO Box 44540 Olympia WA 98504-4540 AFFIRMATION Today's Date Printed name of party signing this report Title 08/17/2012 Maulitta Brown Office Manager The party signing this report pays or supervises the (Name of contractor or subcontractor) payment of the persons employed by: B&B Utilities and Excavating, LLC Project Name: For the week starting: For the week ending: SE 5TH ST AC WATER MAIN REPLACEMENT 08/06/12 08/11/12 "USUAL BENEFITS" DISTRIBUTION (Please report in "per hour" terms) Work Classification Total Hourly "Usual Benefits" (A+B+C+D+E) (A) Hourly Pension (B) Hourly Medical (C) Hourly Vacation (D) Hourly Holiday (E) Approved Apprentice Program 1. Laborer $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2.Dump Truck $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3.Operator $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4.Laborer $ 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5.Laborer $ 0.00 6.Laborer $ 0.00 7. $ 0.00 8. $ 0.00 9. $ 0.00 10. $ 0.00 The party signing below AFFIRMS the following: (1) All information contained in this Certified Payroll Report, including any addenda, is correct and complete. (2) The wage rates for workers, laborers or mechanics as reported above are not less than the applicable wage rates contained in any wage determination related to the contract; and the classifications as reported above for each worker, laborer or mechanic conform with the actual work performed by such worker, laborer or mechanic. (3) The payments of usual benefits as listed above have been or will be made to appropriate approved plans, funds or programs for the benefit of such employees. (4) All persons employed on the above -referenced project(s) have been paid the full weekly wages earned, and no rebates have been or will be made either directly or indirectly to or on behalf of the above -named contractor or subcontractor from the weekly wages earned by any person. No deductions, other than those which are legally permissible, have been made by any person either directly or indirectly from the full wages earned. (5) Any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with the Washington State Apprenticeship and Training Council. Falsification of any of the above statements is a violation of RCW 39.12.050 subject to pros T " n, s nc ns, a pr I Ities. Print or type name of party signing this report Title Signature Maulitta Brown Office Manager \ I f F700-065-000 certified payroll report backer 05-09 U.S. Department of Labor PAYROLL Employment Standards Administration (For Contractor's Optional Use; See Instructions at http://www.dol.goy/whdlforms/wh347instr.htru) Wage and Hour Division persons are not required to respond to the collection of Information unless it displays a currently valid OMB control number NAME OF CONTRACTOR 2 OR SUBCONTRACTOR ❑ ADDRESS B & B Utilities And Excavating LLC 23431 45th Ave SE, BOTHELL, WA 98021-9015 PAYROLLNO. FOR WEEKENDING PROJECT AND LOCATION 08/31/12cr� 08/19!2012 King County 1 2 3' 141 DAY AND DATE (51 (el (7, U.S. Wage and Hour Division Rev. Dec.2008 OMB No.: 1235-OOD8 Expires: 01 /31/2015 tOJECT OR CONTRACT NO. 1 O ( 1 (8! NAME AND INDIVIDUAL IDENTIFYING NUMBER (e.g., LAST FOUR DIGITSOFSOCIALSECURITY WORK Aug � 13 $ Mon - Aug l9 Sm TOTAL RATE GROSS AMOUNT DEDUCTIONS Aug ld Aug IS Aug 16 Aug 17 Aug ]8 Tue Wed Thu Fn Sm WITH- OLDING STATE OTHER NUMBER) OF WORKER 4 CL4SSIFI CATION ° HOURS PAY EARNED FICA TAX TAX TAX OTHER HOURS WORKED EACH DAY Pownall, Kevin D P"4,e92srs 0 0.00 0,50 0.00 0.00 0.00 0.00 0.00 o.sD 6o.oa 790.59 Id:847 0 LAbervr 790.59 s 7.00 8.00 4.00 M00 0,00 0,00 0.00 1900. 40.03 M NET WAGES TOTAL PAID )ucTioNs FOR WEEK While completion of Fo.m WIT-347 is optional, it is mandatory for covered contractors and subcontractors performing, work on Federally financed or assisted comtrueiinn contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3, 5, 5(a). The Copeland Act (40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "famish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Deparur t of Labor (DOL) regulations at 29 C.F.R. § 5.5(a)(3xii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis -Raton prevailing wage rate for the work performed. DOI. and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, starching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. If you have any wmmmits regarding these estimates or any other aspect of this collectinn, including suggestions fur reducing this burden, send them to the Adtrtuusuator, Wage and Hour Division, ESA, U.S. Department of Labor, Room S3502, 200 Constitution Avenue, N.W Washington, D.C. 20210 Date 08/29/2012 (Name of Signatory parry) (Ity) do hereby state: (1) That I pay or supervise the payment of the persons employed by B & B Utilities And Excavating LLC on the (Contractor or Subcontractor) King County Laborer ; that during the payroll period commencing on the (Building or Work) 13 day of August 2012 , and ending the 19 day of August 2012 all persons employed on said project have been paid the fug weeldy wages earned. that no rebates have been or will be made either directly or indirectly to or on behalf of said B & B Utilities And Excavating LLC from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other then permissible deductions as defined in Regulations, Part 3 (29 C.F.R Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108. 72 Stat. 967; 76 Stet. 357; 40 U.S.C. § 3145), and described below. (2) That any payrolls otherwise under this contract required to be submitted for the above penod are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in the wage determination incorporated into the contrail; that the classifications set forth therein for each laborer or mechanic Conform with the work he performed. (3) That any apprentices employed In the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau Of Apprenticeship and Training, United States Department of Labor, or it no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed In the Contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS Partial Reporting Period: Reporting Dates 08/ 1312012 through 08/1912012, For the payroll period beginning 08/13/2012 and ending 0811712012. NAME ANO 71TLE i� l l i SIGNAT RE f r1 /jI t T14=1MLLFUL FALI3IFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT E OR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION S6Jf OFT E to AND SECTION 271 OF TITLE 31 OF THE LV:ITED STATES CODE. U.S. Department of Labor PAYROLL ^ "M Employment Standards Administration (For Contractor's Optional Use; See Instructions at http://www.doLgov/whdfformvwh347instr.htm) Wage end Hour DlviSiOn O.S. Wage and Hour Division Parsons are not required to respond to the collection of infDmtation unless it displays a currently valid OMB control number. Rev. Dec. 2008 NAME OF CONTRACTOR 10 ORSUSCONTRACTOR 13 ADDRESS OMB NO.: 1235-0008 B & B Utilities And Excavating LLC 23431 45th Ave SE, BOTHELL, WA 98021-9015 Expires: 01 /31 /2015 PAYROLL NO. FOR WEEK ENDING PROJECT D LOCA ON PROJECT OR CONTRACT NO. 08/31/12- 08/19/2012—atr&c (4) DAY AND DATE (5) (B) (7) (g) (B) 0) (2) (3} Aug Aug Aug Aug Aug Aug Aug DEDUCTIONS 13 lu 15 la t7 18 19 NET NAME AND INDIVIDUAL IDENTIFYING NUMBER (e.g., LAST FOUR DIGITS OF SOCIAL SECURITY WORK GROSS WITH- WAGES � Mun Tua WeJ Ihu Fri Sat Sun TOTAL RATE AMOUNT GLUING STATE OTHER. PAID NUMBER) OF WORKER >1 GLASSIFICATICN TOTAL t+ouRs WORKED EACH DAY HOURS OF PAY EARNED FICA TAx TAX TAX OTHER DEDUCTIONS FOR WEEK Coulson, Mall R 1d: 251 0 Operatives 0,00 0.50 0.00 0.00 0.00 0.00 0,00 0.50 7422 779.31 y` 0�! 'nO b>✓ 6 $ �� 7 q s 7.0o 8.00 0.00 0.00 a.00 o.00 o.o0 15.00 49.48 (Semiskilled) / While completion of Form RN-347 is opticnal, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 33, 5.5(a). The Copeland Act (40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Department of Labor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a sighed "Statement of Compliance indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructious, scathing wasting data sources, guthering and maintaining the data needed, and completing and reviewing the collection of information. Ifyou have any comments segarding these estimates or airy other aspect ofthis collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Flour Division, FSA, U.S. Department of Labor, Room S3502, 200 Constitution Avenue, N.W. Washington, D.C. 20210 (over) aaagizalz 1 1 P kill ('t It o`IL��✓1 e (Name Of Signatory warty) � (fltla do hereby stele: (1) That I pay or supervise the payment of the persons employed by B & B utilities And Excavating LLC on the (Contractor or Subcontractor) PW King Co Operator ; that during the payroll period commencing on the (Building or Work) 13 day of August 2012 , and ending the 19 day of August 2012 4 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said B & B Utilities And Excavating LLC from the full (Contractor or Subcontractor) wee Id wages earned by any person and that no deductions have been made either diredly or ind'redly from the full wages earned by any person, other then permissible deductions as defined in Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Ad, as amended (48 Stet. 948, 63 Stat. 108, 72 Slat. 967; 76 StaL 357; 40 U.S.C. § 3145), and described below- (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in the wage determination incorporated into the contract: that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor (4) That. (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS — — in addition to the basic hourly wage rates paid to each laborer or mechanic listed In the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed In the contract, except as noted In Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS Partial Reporting Period: Reporting Dates 08/13/2012 through 08/19/2012. For the payroll period beginning 08/13/2012 and ending 08/17/2012. NAME AND TfTLE TUR / FUL FAUSIFICATION OF ANY OF THE A60VE STATEM Y 9UBUECT . HE cONTRALTOR OR SUB TRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEES 10a1 OF TITLE 18 AND SECTION 231 OF TIRE 11 of THE UNITED STATES CODE. U.S. Department of Labor PAYROLL A'" NO Employment Standards Administration (For Contractor's Optional Use; See Instructions at bttp://www.dol.gov/wbd/forms/wh347imstr.htm) and Hour Division Wage and Hour Division persons are not required to respond to the collection of information unless it displays a currently valid OM8 control number. U.S. W Rev, Dec.. 2008 NAME OF CONTRACTOR m OR SUBCONTRACTOR ❑ ADDRESS OMB No.: 1235-0008 B & B Utilities And Excavating LLC 23431 45th Ave SE, BOTHELL, WA 98021-9015 Expires: 01/31/2015 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 08/31/12- 09/19/2012 King County &,—l- k l- t A e!�t a (4) DAY AND DATE (5) (t3) (7) (g) (1) {.') (3) (8) Aug I Aug I Aug Aug Aug Aug Aug DEDUCTIONS NAME AND INDIVIDUAL IDENTIFYING NUMBER ^ d 2 13 f4 l5 IG I) la 19 NET GROSS WAGES (e.g.. LIST FOUR DIGITS OF SOCIAL SECURITY NUMBER) b 1 s �# WORK WITH- a Mon 7-ue Wed Thu Fr. 5nl Sun TOTAL RATE AMOUNT OLD NG STATE OTHER TOTAL PAID OF WORKER z CLASSIFICATION ° HOURS WORKED EACH Dnv HOURS DFPAY EARNED FICA TAX TAX TAX OTHER DEDucnoNS FOR WEEK Hampton, Adam D Id: 667 Q o 1-a}�ewrs (' ed) 0.00 0.50 0.00 0.00 0.00 0.00 0.00 0.50 61.16 2'13 JJ ps J 7.00 e,00 0.00 0.00 0.00 0.00 0.00 15.00 40.77 s �� 1 Y 642.13 While completion of Form Wl 1-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3, 5.5(a). The Copeland AU (40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "famish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Department of Labor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or finaacing the construction project, accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis -Bacon pnevailing wage rate for the work performed. DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching casting data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 1 ryou have any comments regarding these estimates or any other aspect of this coUectionn, including suggestions for reducing this burden, send than to the Administrator. Wage and Hour Division, ESA, U.S. Department of Labor, Room S3502, 200 Constitution Avente, N.W. Washington, D.C. 20210 (over) Di (1) That I pay or supervise the payment of the persons employed by B & B Utilities And Excavating LLC on the (Contractor or Subcontractor) King County Pipelayer that during the payroll period commencing on the (Buii or Work) 13 day of August 2012 and ending the 19 day of August 2012 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said B & B Utilities And Excavating LLC from the full (Contractor or Subcontracto,) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other then permissible deductions as defined in Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Start. 948, 63 Stat. 108, 72 Stet. 967; 76 Stat. 357; 40 U.S.C. § 3145), and described below. (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the gppplicable wage rates cordained in the wage determination incorporated into the contract; that the ass�cations set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered In a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a Stale, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) Than (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS - in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH each laborer or mechanic listed in the above referenced payroll has been paid, as Indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS Partial Reporting Period: Reporting Dates 08/1312012 through 08/19/2012. for the payroll period beginning 08/13/2012 and ending 08/17/2012. AND TITtLE��1�,ttjj��JJ I'NA,YE 1 7T1E1MLLPUL FALISMNCATION OF /V/Y t3F THE ABOVE STATENENTS vSUalEq TjIE NTRACTOR,AR SUBCONTRACTORTOCIVILORCRIMINALPROSECUTION. SEESECTICN 10010E 1 id 231 OF TITLE 31 OF THE UNITED STATES CODE, U.S. Department of Labor PAYROLL Employment Standards Administration (For Contractor's Optional Use; See Instructions at hitp://www.dol.gov/whd/forms/wh347instr.htm) Wage and Hour Division U.S. Wage and Hour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev. Dee- 2008 NAME OF CONTRACTOR (Z OR SUBCONTRACTOR m ADDRESS OMB No,: 1235-0008 B & B Utilities And Excavati ig LLC 23431 45th Ave SE, BOTHELL, WA 98021-9015 Expires: 01/31/2015 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATJON PROJECT OR CONTRACT NO. 08/31/12- 09/26/2012 King Counq VVO.LA-- C L4 �-{ 1 (t) (2) (3) (4) DAY AND DATE (5) (6) (7) (S) (9) Aug .Aug Aug Aug Aug Avg Aug DEDUCTIONS 6 p 20 ZI 22 23 24 25 26 NET NAME AND INDIVIDUAL IOENTIFYING NUMBER o' - Mum T"ue Thu Sat Sun GROSS WITH- WAGES (e.g„ LASI' FOUR DIGITS OF SOCU+L SECURITY o z WORK Wed Fri TOTAL RATE AMOVNT iOLDING STATE OTHER TOTAL PAID NUMBER) OF WORKER CLASSIFICATION HOURS WORKED EACH DAY HOURS PAY EARNED FICA TAX TAX TAX OTHER DEDUCTIONS FOR WEEK Ditienher, Zacb O 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0 00 640 48 3b �? I� 93 (� 53•.29 c �8 Id: 849 3 Laborers (Unskilled) s 0.00 D,00 7,00 9.00 0.00 0.0e O Do 16,00 40.03 640.48 Whdc coinpl.tiui, of Form WH-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §$ 3.3, 5.5(a). The Copeland .Act (40 U.S.C. § 3145) contractors and subcnntractors performing work on Federally financed or assisted construction contracts to 'furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Department of I..abor (DOL) regulations at 29 C.F.R. § 5.5(ax3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a signed "Statement of Compliance" indicating that the payrolls ate correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bactxt prevailing wage rate for the work perforated. DOI. and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection, including time for mviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have say comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, ESA, U.S. Doparuucnt of Labor, Room S3502, 200 Constitution Avenue, N.W. Washington, D.C. 20210 (over) Delta 0 9/2012 I, (Name of Signatory Party) a) do hereby state: (1) That I pay or supervise the payment of the persons employed by B & B Utilities And Excavating LLC on the (Contractor or Subcontractor) King County Laborer ; that during the payroll period commencing on the (Builcing or Work) 21, day of August 2012 and ending the 26 day of August 2012 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or Indirectly to or on behalf of said B & B Utilities And Excavating LLC from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other then permissible deductions as defined in Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 946, 63 Stat. 108, 72 Stat. 967: 76 Stat. 357, 40 U.S.C. § 3145), and described below. (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and compete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage Was contained in the wage determination incorporated into the contract: that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no Such recognized agency exists in a Stale, are registered with the Bureau of Apprenticeship and Training, United Slates Department of Labor. (4) That (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted In Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS Partial Reporting Period: Reporting Dates 08/202012 through 08/2612012. For the payroll period beginning 0820/2012 and ending 0824/2012. NAME ANO TITLE ( SIGNATURE rNE IMLLti1L FAUSIRCATION OF ANY OF THE ABOVE STATEMENTS MAf SuaJ ECT THE CONTRACTOR OR SU8CONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED STATES CODE. U.S. Department of Labor PAYROLL RMMM Employment Standards Administration (For Contractor's Optional Use; See Instructions at bttp://www.doLgov/whd/forms/wh347instr.htm) Wage and Hoar Division U.S. Wage and Hour Division Persons are not required to respond to the collection ofinformation unless it displays a currently valid OMB control number. Rev. Dec. 2008 NAME OF CONTRACTOR 0 OR SUBCONTRACTOR O ADDRESS OMB No.: 1235-0008 B & B Utilities And Excavating LLC 23431 45th .Ave SE,, BOTHELL, WA 98021-9015 Expires. 01/31/2016 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCAT - I..n-tFCT OR CONTRACT NO. (.A 08/31/12- 08/26/2012 PW King Co _ l � — (1) (2) (3) (4) DAY AND DATE (5) (6) (7) 9 (9) Aug Aup, Aug AugMEACH.AY Aug (1 DEDUCTIONS 20 21 22 2326 NET NAME AND INDIVIDUAL IDENTIFYING NUMBER Zi E K `o GROSS WAGES WITH„ (e.g., LAST FOUR DIGITS OF SOCIAL SECURITY ( a WORK Mon Tue Wed ThuSun TOTAL RATE AMOUNT OL01NG STATE OTHER TOTAL PAID NUMBER) OF WORKER "R3 � CLASSIFICATION a HOURS F PAY EARNED FICA TAX TAX TAX OTHER DEDUCTIONS FOR WEEK HOURS WORKED Pownall, Kevin D 0.0o D.00 o.00 D.00 o.00 o.ao o.00 0.00 0.00 g30 Id:847 0 ''9` 214 S 5.50 0.000.00 0.00 000 5.507S While completion ofForm WH-347 is optional, it is mandatory for covered contractors and subcoutinlors perforrnring work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3, 5.5(a). The Copeland Act (40 U.S.C. § 3145) contractors and subcontractors perfarming work on Federally financed or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee during the preceding week.'ITS. Depamnent of Labor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the cormauction project, accompanied by a sighed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis -bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this information review the innfour atim to determine that employees have received legally required wages and fringe benefim Public Burden Statement We eswurne that u will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. Ifyou have any comments regarding these estimates or any other aspect ofthis collection, including suggestions for reducing this burdee., send them to the Administrator, Wage and Hour Division. ESA, U.S, Department of Labor, Room S3502, 200 Constitution Avenue, N.W. Washington, D.C, 20210 (ova') a do hereby state: (1) That I pay or supervise the payment of the persons employed by B & B i hilities. And Excavating LLC on the (Contractor or Subcontractor) PW King Co Operator that during the payroll period commencing on the (Building or Work) 20 day of August 2012 and ending the 26 day of August 2012 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or Indirectly to or on behalf of said A & B Utilities And Excavating LLC from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the fIr wages earned by any person, other then permissible deductions as defined in Regulations, Part 3 (29 C.F.R, Subtltle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat, 357; 40 U.S.C. § $145), and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not Jess than the applicable wage rates contained In the wage determination incorporated into the contract; that the classifications Set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered In a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeshlp and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor, (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS in addition to the basic hourly wage rates paid to each laborer or mechanic listed in l the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH — each laborer or mechanic listed in the above referenced payroll has been paid, as Indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS Partial Reporting Period: Reporting Dates 08/20/2012 through 08/26/2012. For the payroll period beginning 08/20/2012 and ending DS/24/2012. NAME AND TITLE SIGNATURE E WILLFUL FAIJSIFICATION OF AW OF THE ABOVE STATEMENTS MAY SUaJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIAL OR CRIMNAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED STATES CODE. U.S. Department of Labor Employment Standards Administration Wage and Hour Division PAYROLL (For Contractor's Optional Use: See Instructions at bttp://www.doLgov/wbd/forms/wh347instr.htm) Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. No U.S. Wage and Hoar Divtsba Rev. Dec. 2008 NAME OF CONTRACTOR CZ OR SUBCONTRACTOR ADDRESS OMB No.: 123"008 B & B Utilities And Excavating LLC 23431 45th Ave SE. BOTHELL, WA 98021-9015 iExplres: 01/31/2015 PAYROLL NO. 08/31 /12- FOR WEEK ENDING 08/26i2012 PROJECT AND LOCATION ev tE OR CDNTRAC King County (t) (2) (3) (4) DAY AND DATE (5) (0) (7) (8) (q) Aug Aug Aug Aug Aug Aug Aug DEDUCTIONS NAME AND INDIVIDUAL IDENTIFYING NUMBER (e,p„ LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER) OF WORKER c �°- o .- o WORK CLASSIFICATION 7.n 21 22 23 24 25 2G TOTAL HOURS RATE PAY GROSS AMOUNT EARNED NET WAGES PAID FOR WEEK o Mon Tux wed lhu tri Set Sun FICA WITI4 OLDING TAX STATE TAX UTt{ER TAX OTHER TOTAL, DEDUCTIONS HOURS WORKED EACH 7AY Pownatl, Kevin D Id: 847 0 Pipe Layers o 0,00 1..50 0.00 1,00 5,00 0.00 000 7.50 61 15 1.620.61 r 5'� 10 3.06 S 0.00 8.00 B,DO B4OD 4.50 0.00 0.00 28.50 40.77 1,892.75. While completion of Form W11-347 is optional, it is mandatory for covered contractors and subcontractors performing work nu Federally financed or assisted construction contracts to respond to the information collection contained io 29 C.F.K. §§ 3.3, 5.5(a). The Copeland Act (40 U.S.C. § 3) 45) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "famish weekly a statement with respect to tiic wages paid each employee during the preceding week." U.S. Department of Labor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction prgject, accompanied by a signed "Statement of Comptiance" indicating that the payrolls are wrrect and complete and that each laborer or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work perforated. DOL and federal contracting agencies receiving dus infumudion review the infcxmation to determine that employees have received legally required wages and fringe benefits. Public Borden Statement We csrunate that is will take an average of 55 minuns to complete this collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, ESA, U.S. Department of Labor, Room S3502, 200 Constitution Avenue, N.W. Washington, D.C. 20210 (over) i bl (1) That I pay or supervise the payment of the persons employed by B & 13 Utilities And Excavating L.LC on the (Contractor or Subcontractor) King County Pipelayer ; that during the payroll period commencing on the (Building or Work) 20 day of August 2012 and ending the 26 day of August 2012 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said B & H Utilities And Excavating LLC from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other then permissible deductions as defined In Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Slat. 948. 63 Stat. 108, 72 $tat. 967; 76 Start. 357: 40 U.S.C. § 3145), and described below. (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates Contained in the wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below, (b) WHERE FRINGE BENEFITS ARE PAID IN CASH each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS Partial Reporting Period: Reporting Dates 08/20/2D12 through 08/2612012. For the payroll period beginning 08/2tl/2012 and ending 08/24/2012. NAME AND TITLE SiG T I ;' �� r>1.'nz ,. ,LIRE ( THE VALFUL FALISIFTCATION OF ANY OF THE ABOVE STATEMENTS M SUBCONTRACTOR TO CIVIL OR CRIMINAL PR03ECUrICN. SEE SECTI OF AtiO -1 OF TIRE SS OF THE UNITED STATES CODE. U.S. Department of Labor Wage and Hour Division PAYROLL (For Contractor's Optional Use; See Instructions at www.dol.gov/whdKorms/wh347instr.htm) Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. �. 1\,, .u•,l10ra Rev. Dec. 2008 NAME OF CONTRACTOR m OR SUBCONTRACTOR ADDRESS 23431 45th Ave SE Bothell WA 98021-9015 OMB No.: 1235-0008 B&B Utilities and Excavating LLC Expires: 01/31/2015 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 9/5/12 week 8 09/02/2012 5th ST Watermain - Renton CAG-12-056 (1) (2) (3) (4) DAY AND DATE (5) (6) (7) (9) (8) 8f27 9/28 8n9 8/30 8i31 9/1 9/2 20 6 z DEDUCTIONS NAME AND INDIVIDUAL IDENTIFYING NUMBER o LL o o i o o GROSS NET WAGES Mon Tue wcd Thu Fri Sat Sun WITH- e. LAST FOUR DIGITS OF SOCIAL SECURITY (e.g.. u� H WORK o TOTAL RATE AMOUNT HOLDING TOTAL PAID HOURS WORKED EACH DAY NUMBER OF WORKER z CLASSIFICATION HOURSI OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK $183.52 Butcher, Jack o ID 076 0 Dump Truck Driver $10.37 $20.87 $1.29 $32.53 $150.99 s za, za, 4.00 45.89 Coulson, Matt o $395.84 ID 251 0 Operator $22.37 $43.92 $2.56 $69.85 $326.99 5 na, sou $,00 49.48 000 $1,341.00 Dittenber, Zach o 0NO 0.50 1.00 $60.04 ID 849 3 Laborer $75.77 $124.54 $10.70 $211.01 $1,129.99 S 8W 9W x.W am 32.0 40.03 0.00 Pownall, Kevin o 010 ocp 1.00 $74.22 $1,657.58 ID 847 0 Pipe Layer $93.65 $0.00 $10.70 $104.35 $1,553.23 S e oo 8 M s 00 h (H) 32.0 49.48 O S O 5 O S O S While completion of Form WH-347 is optional, it is mandatory for covered contractors and subcontractor: performing work on Federally, financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3, 5.5(a). The Copeland Ad (40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Department of Labor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this information reviewthe information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S3502, 200 Constitution Avenue, N.W. Washington, D.C. 20210 (over) Date 09/5/2012 Maulitta Brown Office Manager (Name of Signatory Party) (Title) do hereby state: (1) That I pay or supervise the payment of the persons employed by B&B Utilities and Excavating LLC on the (Contractor or Subcontractor) work that during the payroll period commencing on the (Building or Work) 27 day of August 2012 , and ending the 2 day of September 2012 all persons employed on s aid project have been paid t he full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said B&B Utilities and Excavating LLC (Contractor or Subcontractor) from the full weekly wages earned by any person and t hat no deductions hav a been m ade either directly or indirec tly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Start. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. § 3145), and described below (2) That any payrolls otherwise under this contract required t o be s ubmitted for t he abov a period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage det ermination incorporated int o t he c ontract; t hat t he classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) T hat any apprent ices ern ployed in t he abov a period are duly registered in a bona fide apprenticeship program regis tered w ith a St ate apprent iceship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropria to progra ms for the bene fit of such employees, except as noted in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH m — Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS: NAME AND TITLE Maulitta Brown, Office Manager SITU: THE WILLFUL FALSIFICATION O F ANY O F T HE ABO VE ATE S M SUBJ ECT T HE CO NTRACTOR O R SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SE SECT 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED STATES CODE. U.S. Department of Labor Wage and Hour Division PAYROLL (For Contractor's Optional Use; See Instructions at www.dol.govlwhdKorms/wh347instr.htm) Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. 4NN0 Hi Rev. Dec. 2008 NAME OF CONTRACTOR m OR SUBCONTRACTOR ❑ ADDRESS 23431 45th Ave SE Bothell WA 98021-9015 1 OMB No.: 1235-0008 B&B Utilities and Excavating LLC Expires: 01/31/2015 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 09/14/12 week 9 09/09/2012 5th ST Watermain - Renton CAG-12-056 (1) (2) (3) (4) DAY AND DATE (5) (6) (7) (9) ]009/39/49%59/6 9/79/8 9/9DEDUCTIONSNET NAME AND INDIVIDUAL IDENTIFYING NUMBER (e.g., LAST FOUR DIGITS OF SOCIAL SECURITY o ,� or, o_ � WORK 0 , 0 I TOTAL RATE GROSS AMOUNT WAGES PAID Tuc wcJ Thu Fri Sal Sun WITH- HOLDING TOTAL HOURS WORKED EACH DAY NUMBER OF WORKER z H CLASSIFICATION HOURSI OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK Dittenber, Zach 0 $640.48 ID 849 3 Laborer $36.19 $92.54 $5.17 $133.90 $506.58 s 900 xon 16.0( 40.03 0.00 Pownall, Kevin 0 010 0.50 $1,434.92 ID 847 0 Pipe Layer $83.18 $0.00 $9.54 $92.72 $1,342.20 s s im 900 8,00 x o0 29.0 4e.48 0.00 Short, Lance 0 oso 0.50 $60.04 $990.74 ID 006 0 Pipe Layer $67.06 $137.93 $0.00 $204.99 $785.75 s s oc 8.00 800 24.0( 40.03 0.00 0 s 0 s 0 s 0 s 0 s While completion of Form WH-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3, 5.5(a). The Copeland Act (40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Department of Labor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(i) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S3502, 200 Constitution Avenue, N.W. Washington, D.C. 20210 (over) Date 09/14/2012 Maulitta Brown Office Manager (Name of Signatory Party) (Title) do hereby state: (1) That I pay or supervise the payment of the persons employed by B&B Utilities and Excavating LLC on the (Contractor or Subcontractor) work ; that during the payroll period commencing on the (Building or Work) 03 day of September 2012 , and ending the 09 day of September 2012 all persons employed on s aid project have been paid t he full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said B&B Utilities and Excavating LLC (Contractor or Subcontractor) from the full weekly wages earned by any person and t hat no deductions have been m ade either directly or indirec tly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Start. 108, 72 Stat. 967, 76 Stat. 357; 40 U.S.C. § 3145), and described below (2) That any payrolls otherwise under this contract required to be s ubmitted fort he above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage del ermination incorporated int o t he c ontract; t hat t he classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) T hat any apprent ices em ployed in t he abov a period are duly registered in a bona fide apprenticeship program regis tered w ith a St ate apprent iceship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropria to progra ms for the bene fit of such employees, except as noted in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH m — Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS: i I NAME AND TITLE Maulitta Brown, Office Manager T E j T THE WILLFUL FALSIFICATION O F ANY O F T HE ABO VE A NTS A BJ ECT T HE CO NTRACTOR O R SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SE S Ti 01 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED STATES CODE. U.S. Department of Labor Employment Standards Administration Wage and Hour Division PAYROLL (For Con(ractor's Optional Use; See Instructions at http://www-dol,gov/whd/forms/wh3471nstr.htm) Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. .= ' HO U.S. Wage and Hoar Division Rev_ Dec. 2009 NAME OF CONTRACTOR 2 OR SUBCONTRAC-OR ❑ ADDRESS OMB No.: 1235-0008 B & B Utilities And Excavating LLC 23431 45th Ave SF-, BOTHELL, WA 98U21-9015 Expires: 01/31/2015 PAYROLL NO. r 09121 /12-01 1 U FOR WEEK FNpING 09/15/2012 PROJECT AND LOCATION Renton KC Labnrer PROJECT OR CONTRACT NO. I, (2) (5) (c) DAY AND DATE (5) (e) (7) (8) (g) Scp Se'p Se sp 2 sa3p Sep lA Sap 15 NAME AND INDIVIDUAL IDENTIFYING NUMBER (e. p.. LAST FOUR DIGITS OF SOCIAL SECURITY NUMBDR OF WORKER s r `�NORK CLASSIFICATION TOTAL HOURS RATE OF PAY GROSS AMOUNT EARNED DEDUCTIONS NET WAGES PAID FOR WEEK o Sun Mon Tue �tled T.�u Fri Sam FICA WITH- OI.OING TAX STA'E TAX OTHER TAX OTHER TOTAL OEDJCTIONS o HOURS WORKED EACH DAY Short, Lance R Id; 006 o �nh^��r.28 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0 oo 0 00 z 26 85 45 000 000 3 55 117,26 83772s 0,00 8.00 0000.00 0.00 aso 0.00 1250 40.03 Pownalt, Kevin D Id: 847 t��-i%t�.t� O 0.00 0.00 0.00 0.00 1.00 0,00 0.00 ] AO 60.05O Z 24 R7 U.00 O.OU U.OU 3.13 28 00 1,745.84 s 0.00 C.Do 0.00 4.00 2.00 3.50 0.00 950 40.03 Dillenber, Zach Id: 849 3 O Laborers (Unskilled) 013C10.00 000O 0.00' 0.00 0.00 0.00 Q00 0 58044 32 7y 90,19 0 00 0.00 4.68 12766 1,16643 o,00 f.sU 0.00 O DO 8.00 0.00 0.00 14.50 40 03 s 1,495 29 While completion of Fonn WH-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. ¢§ 3.3, 5.5(a).'fhc Copeland Act (40 U.S.C. § 3145) contractors and subcontractors perforating wock on Federally finnnced or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Departrnent of Labor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal aeency contracting for or financing the construction pro)ect, accompanied by a signed 'Statement of Compliance' indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work per fonued. DOL and teWeral contracting agencies receiving this information review the udorrnation to determine that employees have rcceived legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes 10 complcic this collection, including time for revicwtnr instructions, searching existing data sources, gathering and maimaining the data needed, and completing and reviewing the collection of in f0ruttior,. If you have any comments regarding these estimates or any ether aspect of this collection, including suggestions for reducing this burden, send them to the, Administrator, Wage and I Lew Division, ESA, U.S. Department of Labor, Room S3502, 200 Cousfitutirm Avenue, N W_ Wastuington, D,C. 20210 (over) IF Del® 09/20M12 ZIL (Nome of Slarilftry Party) do hereby stale: (1)1 hat I pay or supervise the payment of the persons employed by B & B Utilities And Excavating LLC on the (Contractor or Subconirac'o) Renton KC Laborer that during the payroll period ccmmencing on the (Building or Work) 09 day of September 2012 , and ending the 15 day of September 2012 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said B & B Utilities And Excavating LLC from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have beers made either directly or indirectly from the full wages earned by any person, other then permissible deductions as defined in Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (40 Stat. 948, 63 Slat. 108, 72 Slat. 967:76 Slat. 357; 40 U.S.C. § 3145), and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in the wage determination incorporated into the contrail; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed In the above period are duly registered in a bona ride apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of tabor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United Slates Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED FLANS, FUNDS, OR PROGRAMS r in addition to the basic hourly wage rates pad to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or wifl be made to appropriate p,ograms for the benefit of such employees, except as noted in section 4(c) below. (b) "ERE FRINGE BENEFITS ARE PAID IN CASH — each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) DCCEPTIONS EXCEPTION (CRAFT) EXPLANATION RFIVARY.S 31 E N ` THE WILLFUL FAU31F F ANY OF ATEMENTS MM SUaicr: RAn.TOR OR SUBCONTRACTOR TO J - O r CRIMINAL PROSECUTION. SEE SCCliO 001 OF T 1e MIO SECTION 231 OF TITLE 31 OF THE UIJITED STA Es CODE. U.S. Department of Labor Employment Standards Administration Wage and Hour Division PAYROLL (For Contractor's Optional Use; See Instructions at h"p.Hviww.dol.gov/wbd/fanns/wkt347instr.htm) Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. U.S. Wage and Hour Division Rev. Dec. 2008 NAME OF CONTRACTOR $1 OR SUBCONTRACTOR ❑ ADDRESS OMB No.: 1235-0008 B & B Utilities And Excavating LLC 23431 45th Ave SE, BOTHELL, WA 98021-9015 Expires; 01/31/201 S PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PRorecr OR CONTRACT NO. 09/2I /12-01 O 09/15/2012 Renton KC Operator C'r I�i-C�S� (21 (3) (4) DAY AND DATE (5) (6) (7) (9) (e) Sep I Sep I Sep I Sap Sep Sep Sep DEDUCTIONS NAME AND DUAL IDENTIFYING NUMBER n9 10 t l 12 13 14 15 GROSS NET WAGES (e.0, LAST FOUR DK31T5OF SOCIAL SECURITY OUR o WORK a Sun Mon Tue Wed Thu Fri Sal TOTAL RATE AMOUNT Wnl+ qNG STATE OTHER PAID NUMBER) OF WORKER CLASSIFICATION HOURS F PAY EARNED FICA TAX TAX TAX OTHER TOTAL DE XXTIONa FOR WEEK ° FtOURa WORItED6ACM DAY Short, Lance R U O.00 0.00 0.00 0.00 1.00 0.00 0.00 1.00 7422 593.76 1d: 006 Q r,` \l - 33.55 101.40 0.00 000 4.21 139.16 837.72 0.1 0.00 D.- 0.00 8.00 2.50 0.00 10.50 49.48 1.09414 Pownall, Kevin D o 0,00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 717.46 Id: 847 0 ('� a 4053 0.00 0.00 0.00 5.10 45.63 1,745.84 s o.oa 0.00 0.00 4.00 8.00 4.50 0.00 14.50 49.48 1,864.43 Ditteaber, Zach o (Unskilled) 0.00 0.00 0.00 0.00 t.oO 0.00 0.00 100 74 22 3Laborers /.221d:849 4.20 11.53 000 0.00 0.60 16.33 1,106.43 00o--0.00 0.00 0.00 000 while completion of Form WH-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3, 5.5(a). The Copeland AU (40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "hurnish weekly a statement with respect to the wages paid each employee during the preceding week.` U.S. Department of tabor (DOL) regulations at 29 C.F.R. § 5.5(ax3 Kii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or fmancing the construction project, accompanied by a sigoad "Statement of Compliance" indicaring that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 ruinutas to camplate this collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the coUcctioo of information, if yam have any comments regarding these estimates or my other aspect ofthis collection, including suggestions for reducing this burden, send them to the Administrator. Wage and Hour Division, ESA, U.S. Department of Labor, Room S3502, J.DO Constitution Avenue, N.W. Washington, D.C. 20210 (over) 09/20/2012 It 1AA0 (1) That I pay or supervise the payment of the persons employed by B & B Utilities And Excavating LLC on the r tCarrtraaor or SubconUactor) Wl///\y� t-- ; that during the payroll period commencing on the (Building or Work) 09 day of September 2012 , and ending the 15 day of September 2012 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said B & B Utilities And Excavating LLC from the full (Contractur or Subcontmclor) weedy wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other then permissible deductions as defined in Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 $tat. 108, 72 Slat. 967; 76 Stat 357; 40 U.S.C. § 3145), and described below. (2) That any payrolls otherwise under this contract required to be submitted for the above Period are correct and complete; that the wage rates for laborers or mechanics Contained therein are not less than the appiicable wage rates contained in the wage derelmination incorporated into the contract- that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH — each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS I I cNIARrs NAME AND TITLE IOFCOIIT UNITED TO dNiI COOEMRMt4 rL PROSECUYION. SEE SECT1o1f ho01 OF 16 SECTION 231 OF TITLE U.S. Department of Labor PAYROLL �H C Employment Standards Administration (For Contractor's Optional Use; See Instructions at http://-bww.dol.goy/whd/forms!wh347instr.btm) Wage and Hour Division Persons Wage and Hour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev. Dec. 2009 NAME OF CONTRACTOR p OR SUBCONTRACTOR 0 ADDRESS OMB No.: 1235-0008 B & B Utilities And Excavating LLC 23431 45th Ave SE, BOTHELL, WA 98021-9015 Expires: 01131/2015 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 09/28/12• \� 091=012 (2) (3) Renton KC Operator (4) DAY AND DATE (5) (6) (7) 1) Sep Sep Sep Sey Sep Sap DEDUCTIONS ti 17 I8 14 20 21 22 NET NAME AND INDIVIDUAL IDENTIFYING NUMBER ( e,g., LAST FOUR DIGITS OF SOCIAL SECURITY o 1.F16 WORK GROSS vdfFH- WAGES MonTue Wed 71ru Fri Sar GLfH- PAID TOTAL RATE AMDUNT STATE OTHERNUMBER) OF WORKER CLASSIFICATION TOTAL oHOURS WORKED EACH DAY HOURS F PAY EARNED FIL A TAX TAX TAX OTHER DEDUCnorts FOR WEEK Coulson, Matt R - o a 00 0.00 0.00 1,501 0.00 0.00 0.00 L50 74 22 507.17 (d: 251 0 '8n5 7797 0.000.00 3.39 110,01 1,55899 s 000 0.00 0.00 8.00 0.00 a00 0.00 8.00 49.48 _ 1 990 83 While completion of Form WH-347 is optional, it is mandatory for covered contractors and subcentracimx perfrmming work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. Q� 3.3, 5.5(a). The Copeland Act (40 U.S. C. § 3145) contmctors and subcontractors performing work on Federally financed or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee during the preceding week" U.S. Department of Labor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work perforated. DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and Gingc benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, ESA, U.S. Department of labor, Room S3502, 200 Constitution Avenue, N. W. Washington, D.C. 20210 (over) Rate 09/26/2012 ! (Name of Signatory Party) (fYk) do hereby state (1) That I pay a supervise the payment of the persons employed by B & B Utilities And Excavating; LLC on the (Cowraaor or Subcontractor) Renton KC Operator ; that during the payroll period commencing on the (Building or work) 16 day of September 2012 and ending the 22 day of September 2012 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said B & B Utilities And Excavating LLC from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other then permissible deductions as defined in Regulations, Pad 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 106, 72 Stat. 967; 76 Slat. 357; 40 U.S.C. § 3145), and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period am correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in the wage determination incorporated Into the contrail; that the classifcailons set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United Slates Department of Labor. (4) That. (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS in addition to the basic hourty wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed In the contract. except as noted in Section 4(c) below. (c)o EPTIONS EXCEPTION (CRAFT) EXPLANATION RFVARRS I NAME A'D TI71.F��C)r I SUBCONTRACTOR TO CIVILTES OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF 11TYr l AND a CTION 231 OF TITLE 31 Of t r U.S. Department of Labor Employment Standards Administration Wage and Hour Division PAYROLL (F'or Contractor's Optional Use; See Instructions at http://www.dol.gov/whd/forms/wh347instr.htm) Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number gaIi/H0 U.S. Wage and Hour Division Rev Dec.2008 NAME OFCONTRACTOR @ ORSUBCONTRACTOR [ ADDRESS OMB No.: 1235-0008 B & B Utilities -And Excavatine, LLC 23431 45th Ave SE, BOTHELL, WA 98021-9015 Expires: 01131/2015 PAYROLL NO FOR WEEK ENDING PROJECT AND I OCATION PROJECT OR CONTRACT NO. 09/28/12 09/22/2012 Renton KC Laborer -' (1) (2) (3) (4) LAY AND DATE (5) (6) (7) (a) (91 Sep lf, Sep 17 Sep 18 Sep t� Sep 20 Sep 21 Scp 22 NAME AND INDrJIDUAL IDENTIFYING NUMBER (e.g., LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER)OFWORKER o a $ YJCRK C:ASSIFICATION TOTAL HORS RATE OFPAY GROSS AMOUNT EARNED DEDUCTIONS NET WAGES PAID FOR WEEK g Sun Mon Tve Wd lim Fri Sa: FICA WITH- G TAX STATE TAX OTHFR TAX OTHER 7cTAt pEDUCTIGNS ° HOURS WORKED EACH DAY Short, Lance R Id: 006 (7 ('��/�% o D.Do 0.00 0.00 1.50 0.00 0.00 0.00 LSQ 60.05 X67 50 33 17641 000 O of) 6.90 233.64 1,231,22 S 0.00 0.00 0.00 8.00 4.00 0.00 0.00 20.00 40.03 Botcher, ,lack I, Id:076 fl /��ya/� o 0 00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Z465.85 11,31 38.20 0.00 0,00 1.90 51.31 1,090.05 s 0.00 0.00 0.00 5.00 0,00 0.00 0.00 5.00 40.03 Pownall, Kevin D Id: 847 O /�(yyJ /�- 0 0.00 0.00 0.00 tso 0.00 0.00 O.Oo 1.50 60.05 490 37 27 71 0,00 0.00 000 3.97 31.68 1,34.21 $ 0.00 2.00 O oD e.00 0.00 0,00 o.oc )0.00 40.03 t, 337.05 Dittenher. 7.ach Id: 849 3 p o 0.00 o.uo O.eO t.5o a.00 0.00 0.00 1..50 60.05 Z383 23 I S 6060 000 i).(N) 3O.000.00 0.00 8.00 40.03 While completion of Form WH-347 is optional, it is mandatory for covered contractors and subconhaclors performing work on Federally financed or assisted constmetion contracts to respond to the information collection contained in 29 CF.R. §§ 3.3, 5.5(a). The Copeland Act (40 U.S.C. § 3145) contractors arid subcontractors performing work on Federally financed Or assisted cwnstniction contracts to "furnish weekly a statement with respect to the wages paid each employee during the preceding week.' U.S. Department of Labor (UOL) regulalions at 29 C.F.R. § 5.5(a)(3)(ii) require contractors to subnut wecWv a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a smbmed "Statement of Complinnre" indicating that the payrolls are correct and complete and ilia( each laborer or mechanic has been paid not less than the proper Davis -Aaron prevailing wage rate for the work perfor cd. DOL and federal contracting agencies receiving this information review the information to deter» ne that employees have received legally rerinrzed wages and fringe bents. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection, including time far reviewing instnrotions, searching existing data sources, gathering and maintaining tine daia needed and completing and reviewing the collection of information. Ifyou have any conintents regarding tlmse estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, ESA, U.S. Dcpammcm of Labor, Roorn S3502, 200 Constitution Avenue, N. W. Washington, D.C. 20210 (over) Date 09/26/2012 (Name of Signatory Pwty) do hweby (date: (1) That I pay or supervise the payment of the persons employed by B & B Utilities And Excavating I.I.0 (Cowractcr or Subcoitraaor) on the Renton KC. laborer that during the payroll period commenting on the (Builcing or Work) 16 day of September 2012 , and ending the 22 day of September 2012 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said B & B Utilities And Excavating LLC (Contrador w Subcontmaor) the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other then permissible deductions as defined in Regulations, Pan 3 (29 C.F.R. Subtitle A), issued by the Secretary of tabor under the Copeland Act, as amended (48 Stat. 948. 63 Stat. 108, 72 Stat. 967, 76 Sted. 357; 40 U.S.C. § 3145), and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in the wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS in addition to the basic hourly wage rates paid to each laborer or mechanic listed in J the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in sedion 4(c) below- (b) WHERE FRINGE BENEFITS ARE PAID IN CASH each laborer or mechanic fisted in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below. EXCEPTION (CRAFT) EXPLANATION U.S. Department of Labor PAYROLL Employment Standards Administration (For Contractor's Optional Use; See Instructions at http://www.dol.goviwhd/forms/wh347instr.htm) Wage and Hour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. iEWHO U.S. Wage and Hour Division Rev. Dec. 2008 NAME OF CONTRACTOR JZ ORSUBCONTRACTOR C, ADDRESS OMB No.: 1235-0008 B & B Utilities nd Excavapng LLC 23431 45th Ave SE, BOTIIELL, WA 98021-9015 Expires: 01/31/2015 PAYROLL 09128/12• FOR WEEK ENDING 09/22/2012 PROJECT AND LOCATION Renton KC Dump Truck PROJECT OR CONTRACT NO. C + - t2L (t) (2) (3) 14) DAY AND DATE {5} (6) (?) (0) (g) Sep Sep Sep Sep Sep Sep Sep DEDUCTIONS NAME AND INDIVIDUAL IDENTIFYING NUMBER (e.g., LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER) OF WORKER 9 k ° s W WORK CLASSIFICATION Ib 17 Ia II 20 21 22 TOTAL HOURS RATE OF PAY GROSS AMOUNT EARNED NF.T WAGES PAfD FOR WEEK 9 Sw, M on Tue Wed Thu Fri Su FICA WITH- GLUING IAX STATE TAX OTHER TAX OTHER TOTAL DEDUCTIONS ° HOURS WORKED EACH DAY Butcher„ lack L // Wk D D.0D 0.00 0.00 D.00 o D0 0.0o 0.0D 0.00 0.00 Id: 076 0 (' S Z Z7R 26 Z? O (l0 0,(N) 124 35.29 1,090.05 o.co o.000.000.00 3.00 0.00 0.00 3.00 45 88 While completion of Farm WH-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3, 5.5(a). The Copeland Act (40 U.S.C. § 3145) com ractors and subcontractors performing work on Federally financed or assisted construction contracts to "famish weekly a statement with respect to the wages paid each employee during the preceding week.' U.S. Depamnent of Labor (DOL) regulations at 29 C.F.R. § $.5(a)(3)(ii) require contractors to submit weekly a copy of all payrulls to the Federal agency amrracting for or financing the construction project, accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer m mechanic has heen paid not less than the proper Davis -Bacon prevailing wage rate for the work perfbmrcd. DOL and federal coutiacting agencies receiving this informatiun review the informatinn to determine that employees have received legally required wages and Ginge benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection, includialt time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of inlbnnation. If you have any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, ESA, U.S. Department of Labor, Room S3502, 200 Constitution Avcnnc, N.W. Washington, D.C. 20210 (over) bate 09/26M12 1. H (A-1A fl.w' l (Name of Signatory Party) do hereby state: 112 (1) That I pay or supervise the payment of the persons employed by B & B Utilities And Excavating LLC on the (Contractor or Subcontractor) Renton KC Dump Truck that duringroll the pay period commencing on the (building or Work) 16 day of September 2012 , and ending the 22 day of September 2012 all persons employed on said pro)ed have been paid the fill weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said B & B Utilities And Excavating LLC from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other then permissible deductions as defined in Regulations, Part 3 (29 C. F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Slat. 948, 63 Slat. 108, 72 Stat. 967: 76 Slat. 357; 40 U.S.C. § 3145), and described below. (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in the wage determination incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conform with the work he performed- (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a Stale apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a Slate, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor- (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS 1 in addition to the basic hourly wage rates paid to each laborer or mechanic fisted in L the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable Basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS NAME ANU TITLE I j J�} SIGNATURE ., Y/ 1 L'� THE WILLFUL FAUSIFICA ION OF TF1E ABOVE STATEMENTS MAYS T THE TOR Off/ SUBCONTRACTOR TO CI l O IMINAL PROSECUTION. SEE SECTION I TITLE ArJD eF.6T1eII L OFTITLE 31 OF THE UNITED STATES CODE. U.S. Department of Labor PAYROLL N 23 Employment Standards Administration (For Contractor's Optional Use; See Instructions at http://www.dol.gov/whd/f`ormstwh347instr.btm) Wage and Hour Division Persons Wage and flour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev Dee, 2008 NAME OF CONTRACTOR 2 OR SUBCONTRACTOR ❑ ADDRESS OMB No.: 1235-0008 B & B Utilities And Excavating LLC 23431 45th Ave SE, BOTHELL, WA 98021-9015 Expires: 0113112015 PAYROLL NO 09/28/12- i\ FOR WEEK ENDING 0922/2012 PROJECT AND LOCATION PROJECT OR CONTRACT NO. ` - PW King Co Operator !CA 1 1 11 (2) (3) (4) DAY AND DATE (5) (6`, (71 Iel (9i Sep IG Sep 17 Sep IS 18 19 Sep 'u Sep Il Sep t2 NAME AND INDMDUAI, IDENTIFYING NUMBER (e.p., LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER) OF WORKER € "- $ # W VVGRK CLASSIFICATION TOTAL HOURS RATE E F PAY CROSS AMOUNT EARNED DEDUCTIONS NET 'WAGES PAID FOR WEEK $ San Mon Tun Wed Tiu Fri Sat FICA WITH- OLDING TAX 57ATE TAX OTHFX TAX OTHFR 7p7gt OEOUCnous 5 HOURS WORKED EACH DAY Coulson, Matt R id: 251 0 p� �"""" 0 0.00 0.00 0.00 0.00 0.0o 0.00 o.o0 0.00 0.00 247.40 13 98 3,904 O 0O O n(I 1 E<i 53.68 1,558.98 aoo s,00 0.00 0.00 0.0o a.00 o.ac 5.00 49.48 s I - - 1 990 $3 While completion of Form VA I-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 CF.R. §§ 3.3. 5.5(a). The Copeland Act (40 U.S.C. § 3145) contractors and subcontractors performing work an Federally financed eA assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Department ofl-abor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(ti) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer or medtartic has been paid not less than the proper Davis -Baron prevailing wage rare for the work performed. DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. if you have any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Admin isbator, Wage and Hour Division, F_SA, U.S. Deparmient of Labor, Room S3502, 200 Constitution Avenue, N W. Washington, D.C. 20210 (over) r• r �%OWN IL'I I. (1) That I pay or supervise the payment of the persons employed by B &c B Utilities And Excavating LLC on the (Contractor or Subcontractor) PW King Co Operator , that during the payroll period commencing on the (Building or Work) 16 day of September 2012 , and ending the 22 day of September 2012 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been of will be made either directly or indirectly to or on behalf of said B & B Utilities And Excavating LLC from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other then permissible deductions as defined In Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (46 Stat. 948, 63 Stat. 108, 72 Stat. 967: 76 Stat 357; 40 U.S.G. § 3145), and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in the wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duty registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognzed by the Bureau of Apprenticeship and Training. United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS In addition to the basic hourly wage rates paid to each laborer or mechanic listed in L J the above referenced payroll, payments of fringe benefits as listed In the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted In section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below, (c) CEPT)ONS EXCEPTION (CRAFT) EXPLANATION RLMAP.KS EAND G'IR�/l IG T RE c t. 11 THECCN;F A. F CATp bF ANY OF 7HPC A80VE STATEMENT 3U8J HE NTRACTOR ` SUBCONTRACT OR CRIMINAL PR ELUTION. St>= S 71te/ TITLE 16 231 OF TITLE 31 OF THE UNITED STATESCODE. LETTER OF TRANSMITTAL SALINAS SAWING AND SEALING, INC. 7804 40th Ave W • Mukilteo, WA 98275 Phone (425) 745-0706 • Fax (425) 745-0628 Lic. #SALINSSO44LO TO B & B Utilities and Excavation P.O. Box 293 Bothell, WA 98041 WE ARE SENDING YOU: JOB NO. 09/07/12 ATTENTION SE 51h St AC Water Main Replacement City of Renton Contract #CAG-12-056 Shop Drawings _ Prints _ Plans _ Specifications Copy of Letter Change Order Samples COPIES DATE NO. DESCRIPTION 2 Certified Payroll #2 and #3 (Including No Work Performed) THESE ARE TRANSMITTED AS CHECKED BELOW: For Approval For Review & Comment For Your Use Approved as Submitted As Requested _ Approved as Noted REMARKS: Returned for Corrections SIGNED: peu If enclosures are not as noted, kindly notify us at once. Salinas Sawing & Sealing, Inc. 7804 40th Ave W. Mukilteo, WA 98275 NO WORK PERFORMED STATEMENT PRIME CONTRACTOR B & B Utilities NAME OF PROJECT SE 51h St AC Water Main Replacement PROJECT NO CAG-12-056 WEEK ENDING 07/15/12 — 07/21/12 07/22/12 — 07/28/12 07/29/12 — 08/04/12 08/05/12 — 08/11/12 08/12/12 — 08/18/12 08/19/12 — 08/25/12 PAYROLL NO. 2 I certify that there was no work performed on the above project for the period of 07/15/12 — 08/25/12 (1�4 a-A Authorized Signature Administrative Assistant Title 09/01/12 Date Department of Labor and Industries Employment Standards Program PO Box 44510 Olympia WA 985044510 (360)902-5316 a4.sT�c p CERTIFIED PROJECT PAYROLL ® Project Name Coun v° Prime Contractor SE 5th St AC Water Main Replace. King SubcontractorIZI Project Address Awarding Agency Name Phone Company Name For the week ending: CIty of Renton Salinas Sawing & Sealing, Inc. Month Day Year Address Cite State ZIP+4 Address 9 / 1 / 12 1055 S. Gradv Wav Renton WA 98055 7804 40th Ave W. City Renton Cite Mitkiltan Project or Contract# CAG-12-056 State WA Phone (425)745-0706 State ZIP+4 WA 98275 Work Classification and Soc Sec# of Employee Name and Address Day and Date Sun Mon Tue Wed Thu Fri Sat Total Hours Rate of Pay Gross Earned Deductions NET WAGES FICA Withhold -ing Tax Other 26 27 2a zs so 1Amount st t Hours Worked Each Day GROUP 4 LABORER CSO 5724 ROBB W SMITH 7710 GRANDVIEW RD ARLINGTON, WA 98223 OT 0.00 0.00 $ 79.25 93.02 325.00 177.01 $ 1,058.46 RG 2.50 2.50 31.70 OT 0.00 0.00 $ 0.00 $ RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 $ 0.00 $ RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 0.00 RG 0.00 F700-065-000 certified project payroll 10-01 Emplovee Benefits Distribution and Signature Certification on Reverse Department of Labor and Industries Employment Standards Program PO Box 44510 Olympia WA 98504-4510 (1) AFFIRMATION Today's Date Name of signatory party Title 09/07/2012 1 Andrea Poua Administrative Assistant The above signatory pays or supervises (Name of contractor or subcontractor) the payment of the persons employed by: Salinas Sawing & Sealing, Inc. Name of building or work project Payroll period starting Payroll period ending SE 5th St AC Water Main Replacement 08/26/2012 09/01/2012 All persons employed on above project have been paid the full weekly wages earned, that no rebates have/will be made either directly or indirectly to or on behalf of the above contractor or subcontractor from the weekly wages earned by any person and that no deduction have been made either directly or indirectly from the full wages earned by any person, other than permissible deduction. (2) That any payroll otherwise inder this contract required to be submitted for the above period are correct and complete, that the wage rates for laborers or mechanics contained therein are not less then the applicable wage rates contained in any wage determination incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conforms with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency. That: (4) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS * In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed below have been or will be made to appropriate programs for the benefits of such employees. The willful falsification of any of the above statements may subject the contractor to civil or criminal prosecution. Print or type name of signatory Title Signature Andrea Poua Administrative Assistant ),�, BENEFIT DISTRIBUTION (Please report in "per hour" terms) Craft/Trade Hourly Total Benefit Credit Hourly Pension Hourly Medical Hourly Vacation LECET / TRAIN LABORERS 9.52 3.70 5.30 0.52 F700-065 backer 10-01 U.S. Department of Labor Employment Standards Administration Wage and Hour Division persons are not required to respond to the collection or information unless it displays a currently valid OMB control number. PAYROLL (For Contractor's Optional Use; See Instructions at http://www.dot.govtwhdifonns/wh347iiistr.htin) AW`N0 U.S, Wage and hour Division Rev. Dec.2008 NAVE OF CONTRACTOR lZ OR SUBCONTRACTOR [, ADDRESS OMB No.: 1235-0008 B & 13 Utilities And Excavating LLC 23431 45th Ave SE, BOTHELL, WA 98021-9015 Expires: 0113112015 PAYROLL NO. 10/05/12-01 ?j FOR WEEK ENDING 09/2912012 PROJECT AND LOCATION Renton KC Operator PROJECT OR CONTRACT NO- Gs tZ ru" r/ (2) (3) (4) DAY AND DATE (5) (s) p) (A) (9�) Sip ~ ,.t Sep 24 set 25 Sep . S27ep Sep 1S Sep 2Y NAME AND INDIVIDUAL IDENTIFYING NUMBER (e.g., LAST FOUR DIGITS CF SOCIAL SECURrry NUMBER) 0= WORKER 11 b WOR CLASSIFICATION TOTAL HOURS RATE OF PAY GROSS AMOUNT EARNED DEDUCTIONS NET WAGES PAID FOR WEEK , Sun Mm Tue Wed Thu Fri Sat FICA WITH- OLDING TAX STATE TAX OTHER TAX OTHER TOTAL DEDUCTIONS HOURS WORKED EACH DAY Pownall, Kevin D 0 0 0.00 0.00 D.D01 0.00 0.00 0.00 0.00 0.00 0.00 /4948Id:847 2.80 000 0.00 000 0 45 3.25 1508,95 s 0.00a.00 o.00 o.00 a.so O.sO o.00 i.00 49.48 RECEIVED OCT 15 2012 CITY OF RENTON UTILITY SYSTEMS While completion of Form WH-347 is optional, it is mandatary for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3, 5.5(a). The Copeland Act (40 U.S.C. § 3145) —tractors and subcontractors performing work on Federally financed or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee during the preceding. weer." U. S. Department of Labor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Fedetal agency contracting, for or financing the constriction project, accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct tied complete and that each laborer or mechanic has been paid trot less than the proper Davis -Bacon prevailing wage rate far itto work performed. DOL and federal contracting agencies receiving this information review the inframarion to determine that employees have received legally required wages and fringe benefits. Public Barden Statement We estinuite drat is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of infomrntion. If you have any comments regarding these estimates or any other aspect of thus collection, including suggestions for reducing this burden, said them to the Administrator, Wage and Hour Division, ESA, U.S. Depatunent at Labor, Room S3502, 200 Constitution Avenue, N.W. Washington, D.C. 20210 (over) Dart Ioro5/2012 (Name of Signatory Party) (Title) do hereby state: (1) That I pay or suparvise the payment of the persons employed by B & B Utilities And Excavating LLC on the (Contractor or Subcontractor) Renton KC Operator that during the payroll period cornmencing on the (Building or work) 23 day of September 2012 and ending the 29 day of September 2012 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said B & B Utilities And Excavating I.LC (Contradw or Subcontractor} the full weekly wages eamed by any person and that no deductions have been made either directly or indlrectly from the full wages earned by any person, other then permissible deductions as defined in Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stal. 948, 63 SIM 108. 72 Stat. 967, 76 Stat. 357, 40 U.S.C. § 3145), and described below- (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the apppplicable wage rates contained in the wage determination incorporated Into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed, (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprentioeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor, (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in lthe above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH each laborer or mechanic listed in the above referenced payroll has been paid, as Indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, exrx'pt as noted in Section 4(c) below, (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION RFMl:RKS NAME AND 7 ITL SIG7i""'EX THE WILLFUL FALISIFICATION THE WE STATftAFATE MAY PUBJE4 E T SuacON'rRACTOR TO (SVIL OR C}tl AL PROSECNION. S SECTION idal Of A lON 231 OF TITLE 31 Or I PIE UNITED STATE$ CODE, U.S. Department of Labor PAYROLL VHM Employment Standards Administration (For Contractor's Optional Use, See Instructions at http://www dol.gov/whd/forms/wh347instr.htm) Wage and Hour Division parsons are not U.S. Wage and Hour Division required to respond to the collection of information unless it displays a currently valid OMB control number. Da., M- ,nna NAME OF CONTRACTOR E OR SUBCONTRACTOR ❑ ADDRESS OMB No.: 1235-0008 B & B Utilities And EXCAu<ng LLC 23431 45th Ave SE, BOTHELL. WA 98021-9015 Expires: 01/31/2015 PAYROLL NO. 10/05/12-01 FOR WEEK ENDING PROJECT AND LOCATION PR1OJE�CT OR CONTRACT NO. 09/29/2012 Renton KC Laborer (4) DAY AND DATE (5) (6) (7) �--✓K -"(� L_� 7C /, lt) (2) (3) gg 524� S 52� DEDUCTIONS NAME AND INOIVIOUAL IDENTIFYING NUMBER S ism 28 t� GROSS NET (e.g.. LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER)OFWORKER WORK t1 Sun Mon Tue Wed Thu Fri Sat `o TOTAL RATE AMOUNT OLD(NG STATE OTHER WAGES PAID CLASSIFICATION HOURS WORKED EACH DAY HOURS FPAY EARNED FICA TAX TAX TAX TOTAL OTHER DEDUOnoNs FOR WEEK Short, Lance R o 0,00 0,00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Q /320.24Id:006 1809 62.93 0.00 0.00 2.30 83.32 1,19&96 0.00 0.00 0.00 5.00O.00 8.00 40.03 10.00 Pownall, Kevin D 0 D.tm 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Q /320.24Id:847 18.09 0.00 000 0.00 2.90 20.99 1,508.95 S0.000.00 0.00 "0 0.00 0.00 0.00 8.00 40.03 Dittenber, Zach 0 0.00 0.00 U.00 0.00 0.00 0.00 0.00 0.()0 0.00 290.21 Id:849 j 15.83 45.47 0.00 0.00 2.55 63.85 1,245.53 5 0.00 D.00 0.00 D.00 7.OD o.00 o.o0 7.00 40.03 1 613.13 While completion of Form W14-347 is optional, it is mandatory for covered contractors and subcontractors perfar ing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3. 5.5(s). The Copeland Act (40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Department of tabor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(ii) requite contractors to submit weekly a copy of all payrolls to the Federal agency e00tractmg for or financing the construction project, auwmpanied by a signed "Statement ofCornpliance" indicating that the payrolls are correct and complete and that each taborer or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this infonnation review the information to determine that employees have received legally required wages and fringe benefits Public Bmden Statement We estimate that is will take m average of 55 minutes to complete this collection, including time for tcviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have my comments regarding these estimates of any other aspect of this collection, including suggestions for reducing this burden, send then to the Administrator, Wage and Hoar Division. ESA, V.S. Department of Labor, Room S3502, 200Constitution Avenue, N.W. Washington, D.C. 20210 (over) Date 10/05/2012 'k CI a Ir�t��c tVA , 6 C (Name of Signatory Parry) (Title) do hereby state: (1) That I pay or supervise the payment of the persons employed by B & B Utilities And Excavating LLC on the (Contmc,or or Subcontractor) Renton KC Laborer that during the payroll period Commencing on the (Building or Work) 23 day of September 2012 ,and ending the 29 day of September 2012 all persons employed on said proved have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said B & B Utilities And Excavating LLC from the frill (ConrracAor ur Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or Indirectly from the full wages earned by any person, other then permissible deductions as defined in Regulations, Part 3 (29 C.F,R, Subtitle A), issued by the Secretary of Labor under the Copeland Ad, as amended (48 Star- 948, 63 Stat. 108. 72 Stall. 967, 76 Slat. 357, 40 U.S.C. § 3145), and described below (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in the wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic Conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of ApprenttoesNp and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS ` — — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in ` the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) bolow. (b) WHERE FRINGE BENEFITS ARE PAID 1N CASH — each laborer or mechanic listed in the above referenced payroll has been paid, r es indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Seclion 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS p1A1E AND TfTLE NA`rry�/ e THB WILLFUL FAt191F1 I F ANY OF THE Ago STATEMENTS MAYS CT TH SUBCONTRACTOR TO C R CRIMINAL PROSLCUTION. SEE SECTION 10 OF TITLE a AND SECTON 23 r OF TITLE 31 OF THE JNIT L'D STATES CODE. LETTER OF TRANSMITTAL SALINAS SAWING AND SEALING, INC. 7804 40th Ave W • Mukilteo, WA 98275 Phone (425) 745-0706 • Fax (425) 745-0628 Lic. #SALINSSO44LO TO B & B Utilities and Excavation P.O. Box 293 Bothell, WA 98041 WE ARE SENDING YOU: Shop Drawings _ Prints Copy of Letter Change Order DATE JOB NO. 10/01 /12 ATTENTION RE: SE 5th St AC Water Main Replacement City of Renton Contract #CAG-12-056 Plans Samples Specifications COPIES DATE NO. DESCRIPTION 2 Certified Payroll #4 and #5 (Including No Work Performed) RECEIVED 0 C T 15 2012 CITY OF RENTON UTILITY SYSTEMS THESE ARE TRANSMITTED AS CHECKED BELOW: For Approval For Review & Comment For Your Use Approved as Submitted As Requested _ Approved as Noted REMARKS: Returned for Corrections SIGNED: If enclosures are not as noted, kindly notify us at once. Salinas Sawing & Sealing, Inc. 7804 40t" Ave W. Mukilteo, WA 98275 NO WORK PERFORMED STATEMENT PRIME CONTRACTOR NAME OF PROJECT PROJECT NO WEEK ENDING PAYROLL NO. B & B Utilities SE 51h St AC Water Main Replacement CAG-12-056 09/02/12 — 09/08/12 09/09/12 — 09/15/12 4 I certify that there was no work performed on the above project for the period of 09/02/ 12 — 09/ 15/ 12 r"�' 14Zdt Authorized Signature Administrative Assistant Title 09/22/12 Date Department of Labor and Industries 6TASS Employment Standards Program o � PO Box 44510 Olympia WA 98504-4510 (360) 902-5316 Awarding Agency Name For the week ending: City of Renton Month Day Year Address 9 / 22 / 12 1055 S. Gradv Way CERTIFIED PROJECT PAYROLL Project Name County Prime Contractor El SE 5th St AC Water Main Replace. Kina Subcontractor Project Address Phone Company Name Salinas Sawing & Sealing, Inc. 01\ State ZIP+4 Address Renton WA 98055 7804 40th Ave W. City Renton City Mukilteo Project or Contract# CAG-12-056 State WA Phone (425)745-0706 State ZIP+4 WA 98275 Work Classification and Soc Sec# of Employee Name and Address d t3 E P1 o oc Day and Date Sun Mon Tue Wed Thu Fri Sat Total Hours Rate of Pay Gross Amount Earned Deductions NET WAGES FICA With -ing Tax Other is tr is is 20 2t 22 Hours Worked Each Day GROUP 4 LABORER CSO 8327 MICHAEL L. PEARIA 8011 N.E. 147TH ST. KENMORE, WA 98028 OT 0.00 0.00 $ 47.55 80.97 175.00 147.80 $ 1,029.33 0 RG 1.50 1.50 31.70 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 $ 0.00 $ RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 $ 0.00 $ RG 0.00 OT 0.00 0.00 0.00 RG 0.00 OT 0.00 0.00 0.00 RG 0.00 F700-065-000 certified project payroll 10-01 Emplovee Benefits Distribution and Signature Certification on Reverse Department of Labor and Industries Employment Standards Program PO Box 44510 Olympia WA 985044510 AFFIRMATION Today's Date Name of signatory party Title 10/01/2012 Andrea Poua Administrative Assistant The above signatory pays or supervises (Name of contractor or subcontractor) the payment of the persons employed by: Salinas Sawing & Sealing, Inc. Name of building or work project Payroll period starting Payroll period ending SE 5th St AC Water Main Replacement 09/16/2012 09/22/2012 All persons employed on above project have been paid the full weekly wages earned, that no rebates have/will be made either directly or indirectly to or on behalf of the above contractor or subcontractor from the weekly wages earned by any person and that no deduction have been made either directly or indirectly from the full wages earned by any person, other than permissible deduction. (2) That any payroll otherwise inder this contract required to be submitted for the above period are correct and complete, that the wage rates for laborers or mechanics contained therein are not less then the applicable wage rates contained in any wage determination incorporated into the contract, that the classifications set forth therein for each laborer or mechanic conforms with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency. That: (4) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS * In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed below have been or will be made to appropriate programs for the benefits of such employees. The willful falsification of any of the above statements may subject the contractor to civil or criminal prosecution. Print or type name of signatory Title Signatur Andrea Poua Administrative Assistant �,L BENEFIT DISTRIBUTION (Please report in "per hour" terms) Craft/Trade Hourly Total Benefit Credit Hourly Pension Hourly Medical Hourly Vacation LECET / TRAIN LABORERS 9.52 3.70 5.30 0.52 F700-065 backer 10-01 U.S. Department of Labor PAYROLL N Q Employment Standards Administration (For Contractor's Optional Use; See Instructions at http://www.dol.gov/whd/forms/wh3471nstr.htrn) Wage and Hour Division Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. U.S. w Re a DCCr 2008 nd Hour [vision NAME OF CONTRACTOR Vj OR SUBCONTRACTOR ❑ ADDRESS OMB No.: 1235-0008 B & B Utilities And Excavating. LLC 23431 45th Ave SE, BOTHELL, WA 9N021-9015 Expires: 01/31/2015 PAYROLL NO. / FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 10/26/12-01 V% 10120/2012 Renton KC Operator (2) (3) (4) DAY AND DATE (5) (tii (7) (g) Oct Oct Oct On Oa On On M DEDUCTIONS NAME AND INDIVIDUAL IDENTIFYING NUMBER 3 o qq Id $ 15 1b I7 SA 19 2n GROSS NET WAGES (e.g., LAST FOUR DIGITS OF SOCIAL SECURITY o p $ WORK San Mon Tue Wed Thu F. Sat TOTAL FLAT, AMOUNT WITH. WITH. STATE OTHER PAID NUMBER) OF WORKER = �# CLASSIFICAI ION HOURS OF PAY FARNEQ FICA TAX TAX TAX OTHER TOTAL Deo:xnoNs FOR WEEK HOURS WORKED EACH DAY Coulson, Matt R O 0.00 0.00 0,00 0.00 0.00 0.00 0.00 0 DO 000 296'SK 1d: 251 16.77 43 34 000 000 2.22 62 33 1,455 54 s coo 0.00 6.00 0.00 0.00 0-00 000 6.00 49.48 1,842 39 While completion of Form WH-347 is optional, it is mandatoy for covered contractors and subcontractors performing work on Fedctally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3. 5.5(a). The Copeland Act (40 U.S.C. § 3145) txmtradors and suhcontrnctors performing work on Federally financed or assisted construction contracts to "furnish weekly a statement with respect to the waprs paid each employee during the preceding week." U.S. Department of Labor (DOL) regulations at 29 C.P.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer or mechnnie has been paid not Icss than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this infonnatiort review the information to detmnine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching existing data sowces, gathering, and maintaining the data needed, and completing and reviewing the collection of information. Ifyou have any corn ments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator. Wage and 1 tour Division, ESA, U.S. Department of Labor, Room S-,502, 200 Constitution Avenuc, N. W. Washington, D.C. 20210 (over) I Oate 2 am* of do her e: (1) That l pay or supervise the payment of the persons employed by B & B Utilities And Excavating LLC on the (Contractor or Subcontract") Renton KC Operator that during the payroll period commencing on the (Building or Work) 14 day of October 2012 and ending the 20 day of October 2012 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said B & B Utilibcs And Excavating LLC (Comractor or Submirdractor) the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other then permissible deductions as defined in Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Ad, as amended (48 Slat 948, 63 Stag. 108, 72 Slat 967; 76 Stat. 357; 40 U.S.C. § 3145), and described below (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less then the applicable wage rates contained in the wage determination incorporated Into the Contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a Ilona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) Tom' (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS - in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as rated in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH 1 ly—each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION r2FMFr±KS •A AI1�. _ l NAMEANDTITLEI Sri THE WILLFUL F kTIONI�O�F ANY OF E VE 3TATAT�EM1lNTS UBJ C RACTOR SUBCONTRACTOR T CIVIL OR CRIMINAL n ECUTION. 9ff sE t O 16 SEC 7 TrTLE 31 OF I HE UNITED STATES CODE. \ / U.S. Department of Labor PAYROLL Employment Standards Administration (For Contractor's Optional Use; See Instructions at http://www.dol.gov/Whd/forrmtwh3471nstr.htm) Wage and Hour Division persons are not required to respond to the collection of information unless it displays a currently valid OMS control number. �N U.S. Wage and Hoar Division Rev. Dec. 2008 NAME OF CONTRACTOR (0 OR SUBCONTRACTOR 0 ADDRESS OMB No.: 1235-0008 B & B Utilities And Excavating LLC 23431 45th Ave SE, BOTHELL, WA 98021-9015 Expires: 01131/2015 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PRnIFr.T nR CONTRACT NO. 10/26/12-01 10/20/2012 Renton KC Laborer (t) (2) (3) (4) DAY AND DATE (5) (a) (7) Oct I4 Oa IS 0a" IG Ocn 17 Oa IB Oa t9 Oa m NAME AND INDIVIDUAL IDENTIFYING NUMBER (e.g_ LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER) OF WORKER 2 g i °_ WORK CLASSIFICATION TOTAL HOURS RATE OF PAY GROSS AMOUNT EARNED DEDUCTIONS NET WAGES PAID FOR WEEK i1 Sun Mon 1-ue Wed Thu Fri Sat FICA WITH_ OLDING TAX STATE TAX OTHER TAX OTHER TOTAL DEDucTk" ° Hout:s trvoRtcED FACH DAY Short, Lance R Id:006 0 0 0.00 D.00 D_00 D.00 0.00 0.00 0.00 0.00 0.00 80.06 4.52 13.37 0.00 0.00 0.57 18.46 803.71 s 0.00 0.00 2.00 0.00 0.00 0.00 0.00 2.00 40.03 1,04466 Dittenber, T.ach Id: 849 3 o 0.00 O.DO 0.00 0.00 o.Do 0.00 0.00 0.00 0.00 240.18 13.57 36 11 0.00 0.00 2.08 51.79 1,1 14 65 s 0.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00 40.03 1421.08 While completion of Form WH-347 is optional, it is mandatory for covered cortracors and suboantactors performing work on Federally financed or assisted construmon contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3, 5.5(a). The Copeland Act (40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee during the preceding wok." U.S. Department of Labor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(ii) require contractors to atmbmit weekly It copy of all payrolls to the Federal agency contracting for Or financing the construction project, accompanied by a signal "Statement of Compliance' indicating that the payrolls art correct and complete and that each laborer or mecbanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any otter aspect of Otis collection, including suggestions for reducing this burden. Bead then to the Administrator, Wage and Hour Division, ESA, U.S. Department of Labor, Room S3502, 200 Constitution Avenue, N.W. Washington, D.C. 20210 (over) lie IOr255nO12 C� VIA l a k_A IC1 /?A 1 A'-- (Nsme offtnefory Perth) (Tfltey LT do hereby state: (1) That I pay or supervise the payment of the persons employed by B & B Utilities And Excavating LLC on the (Contractor or Subconracor) Renton KC Laborer that during the payroll period commencing on the (Buitding or Work) day of October 20t2 , and ending the 20 day of October 2012 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said B & B Utilities And Excavating LLC from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other then permissible deductions as defined in Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary or Labor under the Copeland Act, as amended (48 Stat. W. 63 Slat. 108. 72 Slat. 967: 76 Slat. 357; 40 U.S.C. § 3145), and described below (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in the wage determination incorporated into the contract that the classifications set forth therein for each taborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duty registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or it no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH — each laborer or mechanic listed in the above referenced payroll has been paid, as indicated an the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS NAME AND TITLE T ". P i) �+tl 6—A v �\)" fl THE WILLWLFAl161Fl F OF THE lrrATEMENTB OR 8UaCONTRACTOR TO IVi GW W NIIL PROSECUnDN. SEE SE 31 OF THE UNTED STA CODE. u Payroll Register Page: 1 i #ICertified Job Contractor Customer SE 5th ST AC WATER MAIN NorthShore Paving Inc B&B UTILITIES & EXCAVATING LLC Job Number: BBUTI12 REPLACEMENT #WTR-27-3604 PO Box 1813 23431 45TH AVENUE SE Week Ending: 9/15/2012 RENTON, WA 98055 Bothell, WA 98041 BOTHELL, WA 98021 P ?, ` (-1-'U� Deductions --- Fed. Local Soc Sec No. -------------------- -------- Hours Worked This Job ----------------------------- Gross Pay Fica Other Check # Class 09/10 09/11 09112 09/13 09/14 09/15 09/09 Pay This Job Med Name / Address Mar Exemp. Mon Tue Wed Thu Fri Sat Sun Tot Rate All Jobs State Total Net Pay ANDREW W JESSE -**-6398 R: 0.000 0.000 0.000 0.000 8.500 0.000 0.000 8.500 38.410 326.49 427.64 0.00 15516 91ST AVENUE SE GENERAL LABOR +1.620FR 93.95 18.56 SNOHOMISH, WA 98296 Single 3 0: 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 2237.00 32.44 1664.41 Male +O.000FR 67.5hrs 0.00 572.59 Fringe MEDICAL Total Rate 1.620 1.620 Amount 13.77 13.77 Deduction Emp. W/C Total Amount 18.56 18.56 DENNIS L DELOZIER ' --* -1914 R: 0.000 0.000 0.000 0.000 8.250 0.000 0.000 8.250 47.860 394.84 415.50 0.00 PO BOX 44 ROLLER -PLANT MIX +1.621 FR 102.00 132.01 MANSFIELD, WA 98830 Married 0 0: 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 2542.23 35.22 1857.50 Male +O.000FR 67.5hrs 0.00 684.73 Fringe MEDICAL Total Rate 1.621 1.621 Amount 13.37 13.37 Deduction MEDICAL Emp. W/C Total Amount 113.69 18.32 132.01 KEVIN FINCH -BRIDGE *-**-8706 R: 0.000 0.000 0.000 0.000 5.500 0.000 0.000 5.500 45.100 248.05 373.27 0.00 3819 107TH PLACE NE Truck & Transfer +3.425FR 99.90 138.69 MARYSVILLE, WA 98271 Married 0 0: 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 2378.54 34.48 1732.20 Male +O.000FR 68.75hrs 0.00 646.34 Fringe 401K MEDICAL Total Rate 1.805 1.620 3.425 Amount 9.93 8.91 18.84 Deduction 401K Emp. W/C Total Amount 118.93 19.76 138.69 LOGAN R MCCANN *--**-2043 R: 0.000 0.000 0.000 0.000 7.500 0.000 0.000 7.500 39.660 297.45 513.22 0.00 13102 20TH ST NE ASPHALT RAKER +1.620FR 93.08 107.90 LAKE STEVENS, WA 98258 Single 0 0: 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 2216.26 32.13 1469.93 WHITE Male +O.000FR 66.5hrs 0.00 746.33 Fringe MEDICAL Total Rate 1.620 1.620 Amount 12.15 12.15 Deduction LOAN SUPPORT Emp. W/C Total Amount 25.00 64.75 18.15 107.90 LINDSAY H NELSON *--**-9125 R: 0.000 0.000 0.000 0.000 7.500 0.000 0.000 7.500 48.770 365.78 543.28 0.00 1925 LOMBARD AVENUE Screed Operator +3.571 FIR 109.54 151.28 EVERETT, WA 98201 Married 1 0: 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 2608.19 37.82 1766.27 Male +O.000FR 67.75hrs 0.00 841.92 Fringe 401K MEDICAL Total Rate 1,951 1.620 3.571 Amount 14.63 12.15 26.78 Deduction 401K LOAN Emp. W/C Total Amount 104.33 28.50 18.45 151.28 MARK A MURRAY --**-5517 R: 0.000 0.000 0.000 0.000 7.500 0.000 0.000 7.500 48.770 365.77 325.92 0.00 24030 FLORENCE ACRES RD Screed Operator +1.620FR 69.32 63.96 MONROE, WA 98272 Married 0 0: 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 1650.43 23.93 1167.30 Male +O.000FR 51.25hrs 0.00 483.13 Certified Payroll Register Page: 2 Job Contractor Customer SE 5th ST AC WATER MAIN NorthShore Paving Inc B&B UTILITIES & EXCAVATING LLC Job Number: SBUT112 REPLACEMENT #WTR-27-3604 PO Box 1813 23431 45TH AVENUE SE Week Ending: 9/15/201 RENTON, WA 98055 Bothell, WA 98041 BOTHELL, WA 98021 � a- 1 Deductions -- Fed. Local Soc Sec No. ----------------------------- Hours Worked This Job ---- ----------------------- Gross Pay Fica Other Check # Class 09/10 09/11 09/12 09/13 09/14 09/15 09/09 Pay This Job Med Name / Address Mar Exemp. Mon Tue Wed Thu Fri Sat Sun Tot Rate All Jobs State Total Net Pay Fringe MEDICAL Total Rate 1.620 1.620 Amount 12.15 12.15 Deduction LOAN Emp. W/C Total Amount 50.00 13.96 63.96 SAUL G URIBE '-**-8603 R: 0.000 0.000 0.000 0.000 7.250 0.000 0.000 7.250 44.260 320.89 334.60 0.00 18910 MOUNTAIN VIEW RD NE DUMP TRUCK DRIVER +1.621FR 97.62 38.51 DUVALL, WA 98019 Married 3 0: 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 2324.16 33.70 1819.73 HISPANIC Male +O.000FR 66.75hrs 0.00 504.43 Fringe MEDICAL Total Rate 1.621 1.621 Amount 11.75 11.75 Deduction LOAN Emp. W/C Total Amount 20.00 18.51 38.51 SCOTT D WILLIAMS *-**-9878 R: 0.000 0.000 0.000 0.000 5.000 0.000 0.000 5.000 45.100 225.50 287.49 0.00 21820 3RD PLACE W Truck & Transfer +3.424FR 83.84 99.38 BOTHELL, WA 98021 Married 0 0: 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 1996.36 28.95 1496.70 Male +O.000FR 68hrs 0.00 499.66 Fringe 401K MEDICAL Total Rate 1.804 1.620 3.424 Amount 9.02 8.10 17.12 Deduction 401K Emp. W/C Total Amount 79.85 19.53 99.38 Hours Pay Regular 57.000 2,544.77 Overtime 0.000 0.00 57.000 2,544.77 + Certified Payroll Register Page: 3 Job Contractor Customer SE 5th ST AC WATER MAIN NorthShore Paving Inc B&B UTILITIES & EXCAVATING LLC Job Number: BBUTI12 REPLACEMENT #WTR-27-3604 PO Box 1813 23431 45TH AVENUE SE Week Ending: 9/15/2012 RENTON, WA 98055 Bothell, WA 98041 BOTHELL, WA 98021 1 l KJ- 1, Theresa Nelson, Controller do hereby state: 1 ] That I pay or supervise the payment of the persons employed by NorthShore Paving Inc on the SE 5th ST AC WATER MAIN that during the payroll period commencing on 9/9/2012 and ending 9/15/2012, all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said NorthShore Paving Inc ( Subcontractor) from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A) , issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. 276c) , and described below: 2] That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. 3] That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. 4] That: ( a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS XX --- In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4 ( c) below. (B) WHERE FRINGE BENEFITS ARE PAID IN CASH ---Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4 ( c) below. ( c) EXCEPTION ( CRAFT) EXPLANATION REMARKS Name and title signature Theresa Nelson, Controller G The Willful Falsification Of Any Of The Above State -its May Subje The Contractor Or SubContractor To Civil Or Criminal P secution. See Section 1001 Of Title 18 And Section 231 Of Title 31 Of Th United States. NOTICE OF COMPLETION OF PUBLIC WORKS CONTRACT Name & Address of Public Agency City of Renton 1055 S Grady Way Renton, WA 98057 UBI Number: 177000094 Contractor's UBI Number: Date: 602619105 01/29/2013 Department Use Only Assigned to: Date Assigned: Nntire i.c hP.rP.hv given relative to the comnletion of contract or nroiect described below Project Name Contract Number Job Order Contracting SE 5th Street AC Water Main Replacement Project CAG-12-056 ❑ Yes [21 No Description of Work Done/Include Jobsite Address(es) Work located on SE 5th Street in Renton, WA approximately 350 feet east of Maple Valley Hwy (SR169) and consisted of the installation of 1,720 feet of new 8" ductile iron water main. Federally funded road transportation project? ❑ Yes No Contractor's Name Telephone Number B&B Utilities and Excavating, LLC 425-398-5906 Contractor Address 23431 45th Ave SE, Bothell, WA 98021 If Retainage is Bonded, List Surety's Name (or attach a copy) Surety Agent's Address Date Contract Awarded Date Work Commenced Date Work Completed Date Work Accepted 05/14/2012 107/12/2012 109/28/2012 110/01/2012 Contract Amount Additions ( + ) Reductions (- ) Sub -Total Amount of Sales Tax Paid at 9.500% (If various rates apply, please send a breakdown) TOTAL Plonep List nll Cnhvnntrnrtnrc Relmv- $ 271,070.00 $ 24,359.12 Liquidated Damages $ $ 33,000.00 Amount Disbursed $ $ 262,429.12 Amount Retained $ $ 24,930.77 $ 287,359.89 TOTAL $ NOTE: These two totals must be equal 274,238.43 13,121.46 287,359.89 Subcontractor's Name: UBI Number: Affidavit ID (if known) Salinas Sawing and Sealing, Inc. 601717158 427262 Northshore Paving, Inc. 600635278 Concrete Services, Inc. 601334103 F215-038-000 08-2011 REV 31 0020e(08/25/11) Continued on page 2 Please List all Subcontractors Below: Subcontractor's Name: UBI Number: Affidavit ID (if known) Comments: Contact Name: Natalie Wissbrod Title: Accounting Assistant Email Address: nwissbrod@rentonwa.gov Phone Number: 425-430-6919 isiote: ine uisoursing unicer must somit inis compietea notice imme is e y arter acceptance or me worK aone unaer inis contract. NO PAYMENT SHALL BE MADE FROM RETAINED FUNDS until receipt of all release certificates. Submitting Form: Please submit the completed form to all three agencies below. For a faster response, please submit by e-mail. Washington State Department of Revenue Public Works Section PO Box 47474 Olympia WA 98504-7474 (360)725-7588 FAX (360) 664-4159 PWC@dor.wa.gov Washington State i� Department of Labor and Industries ;lam Contract Release PO Box 44274 Olympia, WA 98504-4272 (360)902-4754 FAX (360) 902-6897 ContractRelease@lnl.wa.gov arWashington State rf Employment Security Department Specialized Collections Unit PO Box 9046 Olympia WA 98507-9046 (360)902-9780 Fax (360) 902-9287 publicworks@esd.wa.gov For tax assistance or to request this document in an alternate format, visit http://dor.wa.gov or call 1-800-647-7706. Teletype (TTY) users may call (360) 705-6718. F215-038-000 08-2011 REV 31 0020e (8/25/11)