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Home My WebLink AboutWWP2700381(12) Rehabi - Intents & Af f ida i- . BC C ` . � 1 BEGINNING OF FILE TiTLE y.;,.rr•:)^d•r1'TI•Ti�.'�.."li""_r_ �t i- i.K. .. :.��-v �.l;•.1'�.y:.s..i�..:.i`...-. • ..:�:...._a. :' iC .. ..... _. .t.... DEPARTMENT OF LABOR AND INDUSTRIES Nl.temer ul EMPLOYMENT STANDARDS DIVISION A INTENT TO PAY A gpr.•wA99aoa \Z?V PREVAILING WAGES (Puhlir Work.Contract) MAY 27 1982 �1 Contras AxardVng Agency City_of..FeaCan, Pudlia..NArks LY`j ae Contract Number CAG015-87 u...nHA Vat Contract Bid Opening Date February 41,„_3987 JUN R 19 Date Contract Axarded march 0...A04.. _..__ ......., County in Which Work Performed ._.wituit_............_._.._................. l STATE OF WAANINOTON Location Wdh;n County Rantart'a"A.__.._..........._.......__. 1 / 1 S\\\ Prone Contractor _Ford.LoaatJ;uCt(OO..fdlt..............._....._._ Counil.al KING_____.._„_,,,,, Do You Intend To Use Subcontractors? Yes 0 No(] In compliance with RCW 39.12.040 I, the undersigned, being a duly authorized representative of - FORD CONSTRUCTION CO. P. 0, Box 5036, Kent, Washington 98031 nbnen.m.�r sonr.,ntnrna Admr.., do hereby certify that the following rates of hourly wage and hourly fringe benefits will be paid to all laborers, workmen and mechanics employed by me upon the public works project described above and that no laborer, workman or mechanic will be paid lees than the "prevailing rate of wage" as determined by the Industrial Statistician of the Department of Labor and Industries. PLEASE NOTE: If apprentices are to be used they must be registered with the State Apprentice. ship Council or they must be paid prevailing journeyman wages. CMAFr RATE Of RATE OF HOURLY HOURLYPAY FRINGE BENEFITS Laborer. tone)-- Group 1-B) 14.30' 2.58 operating Engineer (one) - Group 7 lh6.1 3.11 Nimnt Ateach Additional Sheeta.8 Needed CpNST T C Subscribed and sworn to before me By rnu.,Caa this �:`'. day of..._._Ma'1...___.__ For La I U.Ordy 19_. _ b1 APPRO .1) Depar nl of labor A Industries Ind 1 Slatieti ' n Q' .V„ro•r Hr61ie in and R+r b W WalMnsfon. +� ->✓J m.•dmx in wssAinaN., DIY. 0.Y BEFORE FINAL SETTLEMENT can be made on any public works project,the prime ccntractor Lnd each and every subcontractor must submit form LI.700-7 "Affidavit of Wages Paid" to the officer charged with the disbursement of public funds. EACH AFFIDAVIT OF WAGES PAID j MUST BE CERTIFIED BY THE INDUSTRIAL STATISTICIAN OF THE DEPARTMENT OF i LABOR AND INDUSTRIES BEFORE IT IS SUBMITTED TO SAID OFFICER. PROGRESS PAYMENTS:Each voucher claim submitted to an owner by a contractor for payment - on a project estimate shall state that prevailing wages have been paid in accordance with the pre- filed statement or statements of intent to pay prevailing wages on file with the public agency. COMPLETE AND MAIL ENTIRE SET FOR APPROVAL TO: Employment Standards Division, Department of Labor and Industries, General Adminiatration Building,Olympia,Washington 98504 CON TRACTORS, DISTRIBUTE APPROVED STATEMENTS AS FOLLOWS: (PINE COPY) ORIGINAL CONTRACT AWARDING AGENCY (GREEN COPY) DUPLICATE-INDUSTRIAL STA',aSTICIAN IRe nned by D,,,ne,m) (BLUE COPY) TRIPLICATE--PRIME CONTRACTOR (YELLOW COPY)QUADRUPUCATE-SUBCONTRACTOR J Lnt.029 Rw,to P.y (74o t� MAIL TO. Statement of INDI.ISTRIAL STATISTICIAN INTENT TO PAY Urparlment of Labor a Industries PREVAILING WAGES Eaploytnea. Standard. Division General Administration Building Ecvjq-n (Public Works Contract) Olymill"p7FS 1 W0ASR04 ) Mqp 1 } 1947 �'1lhr AttYqu Contract Number CAC+ 006-83 Contract Awarding Public Agency Date Bid Was Due�- nor IQaa C41r1of RentoNDeot of PubliC!RrksCuunt) in Which Work Performed ring Adu.csa 200 Mill Avenue South Location Within County_ Renton RarkoD is mhi.,�,,.. Qnncc____ Prime Contractor Phone +25-2611 _____._ Contractor, Registration Certificate No cr nr.650-1at I)(, You Intend To Use Subcontractors? Yes E No In compliance with RCW 39A2.040 1. the undersigned, being a duly authorized representative of Ford Crnstructim Co_ P. O. ROIr 5036. Kent, Washinton 98031 ,ltvnrr..r a BalamnanN - ,Add�l do hereby certify that the following rates of hourly wage and hourly fringe benefits will be paid to all laborers,workmen and mechanics emploved by me upon the public works project described above and that no laborer.workman or mechanic will be paid less than the"prevailing rate of wage"as determined by the Industrial Statistician of the Department of Labor and Industries. PLEASE NOTE: If apprentices are to be used they must he registered with the State Apprenticeship Council or they must be paid prevailing journeyman Wages. CRAFT ESTIMATLO NUMN&H MTN OF MTN OF HOURLY OF WORKNRR HOURLY PAY PRISON BENEFIT, Operator- GYOUr ]IC one $17.43 $3.66 Laborers tw $15.26, $2.08, Nors: Attach Additional Sheets as Needed. Ford " atrrEtiw C 1 I Subscribed and sworn to before me r (Tw" N"Ch Par L♦ 1 U.Oaly Ap thin 1Kt'— day of _ , Indu I fjD 19 _ Depart t of Labor • t duatrioa � 1 indu � St$liatiaYa � 15 �j ev �/ Mal ryY altar is wal fir a State W Waahinrr., •rAff M Washout. BEFORE FINAL SETTLEMENT can be made on any public works project,the prime contractor and each and every subcontractor most submit form LI-700-7"Affidavit of Wages Paid"to the officer charged with the disbursement of public funds. EACH AFFIDAVIT OF WAGES PAID MUST BE CERTIFIED BY THE INDUSTRIAL STATISTICIAN OF THE DEPARTMENT OF LABOR AND INDUSTRIES BEFORE IT IS SUBMITTED TO SAID OFFICER. PROGRESS PAYMENTS: Each voucher claim submitted to an owner by a contractor for payment on a project estimate shall state that prevailing wages have been paid in accordance with the prefiled statement or statements of intent to pay prevailing wages on file with the public agency. COMPLETE AND MAIL ENTIRE SET FOR APPROVAL TO: Employment Standards Division, Department oflabor and Industries, General Administration Building, Olympia, Washington 98504 r NTRACTORS, DISTRIBUTE APPROVED STATEMENTS AS FOLLOWS: NH COPY) ORIGINAL CONTRACT—AWARDING AGENCYEEN COPY) DUPLICATE—INDUSTRIAL.STATISTICIAN IRemetd bUE COPY) TRIPLICATE--PRIME.CONTRACTOR LLOW COPY)QUADRUPLICATE-SUBCONTRACTOR u,m n ,r,w Pay,Ami QA A I F• } r IIW.YnV��•Y�-r.. ..a. .Y.'.��f•Lf+ • .... v '"'er-"rtla'l.sa+ir rr.-+.-n.1�AM�/Y/E(��YYi. , . F x SNAIQ'MIF k1t1rJ WFIIMAN ❑,etv Govtxrlor cT ATl(Y NVVIY MW DEPARTMENT OE LABOR AND INDUSTRIES C;rrwral Mhnlm.rramn9uM1"q; . tMntva rt.nlwpr,n 4i9N '7ecemoer 2. !98? r��'A1,(J Ford :.onstruction I"o,i,oany Y P.O. 'Sex 5056 'Cant, SSA 9&031 Re, Firm No. 407,9ttd-J0-5 Contrast 40.(''\r,ril 5-$2 Gentlemene /j-J please x udvisad tha(. the (Xpartment td ( a,or .ad 01,1stnes does ereov release Ford Constrir6on Corspanv froln am B( ther liaodf" pursuant to ?.] 71.12.:50 and ;Z t' Si.t2.'g0 n would oth^rwtce I.:Gx inc.mnection with a contract callinu to a s.:bcontract fm work Ni a pump stein,(for the City of '2:mta- I,us ,,,tf`.(nate dw nc.release Ideal•Laxesi le 'u no and Cquip nc it fro n liaoillty for O a 1(tiona1 contritknions whits later may be deter .Tined to he due with respect to the sve 11ed contract or any other contracts said -ontr actor-nay have oarfonned. t ••rC lorlaug�!' laistrative Assistant i 3O,.tractor Compliance Un(t !si(one: (2llG17`3-J39s Mmu I.'.K.cdk.3.97 ` If _c to Weal-Lakesi,Ie pu,np and ,=quio nnnt N.J.9nx 666 Woodinville, VA 930%t e . _J ra �!' s ?_:*S '�1 .ir+a ,alit'. ' t�i►e.,.�iir DEPARTMENT OF LABOR AND INDUSTRIES Statement of EMPLOYMENT STANDARDS DIVISION INTENT TO PAY Olympia,WA98504 -� PREVAILING WAGES (I'xblic Works Contract) y RECEIVE.D NOV 18198? Awarding Agenep City of Renton, Department of Public Works �eviiittwa[t�,veo Contract Numhrr CAGOIS-82 hate Contract Awarded 611182 l County in Which Work Performed Xing t I Location Within County City of Renton STATE OF WASHINGTON t Prime Contractor Ford Conatruotim Co. Ovum/)'of ............. g J\) N You Intend',o Use Subcontracton' Yes❑ No Gt In compliance with RCW 39.12.040 I, the undersigned, being a duly authorized representative of Ideal-Lakeside Pump and 8quipment P. 0. Box 666, Woodinville, Wash, 98072 tl'oolvrxm m SUM,m �rtop IAddn-. do hereby certify that the following rates of hourly wage and hourly fringe benefits will be paid to all laborers, workmen and mechanics employed by me upon the public works project described above and that no laborer, workman or mechanic will be paid less than the "prevailing rate of wage" as determined by the Industrial Statistician of the Department of labor and Industries. PLEASE NOTE: If apprentices are to be used they must be registered with the State Apprentice. ship Council or they must be paid prevailing journeyman wages. CRAFT RATE OF RATE OF HOURLY HOURLY PAY FRINGE RKNEFITR NOTE. Attach Additional Sheets ax Needed Idea - es'de Pum and Equipment l;> v� Subscribed and sworn to before me """' rr — F��t.A I t'..Del. tht.......Y.1... aayat.....N...�.._ . — APPRONED I9...ti Deparl t of labor& Industrirx Indus i 1 Stx lixtir' n N Aw m ...:!w t xN W N'axhinxton, Rb D te2 9 NOV 1982 ,rrishas'.E4sAinsenn BEFORE FINAL SETTLEMENT can be made on any public works project,the prime contractor and evch and every subcontractor must submit form LI-700-7 "Affidavit of Wages Paid" to the officer charged with the disbursement of public funds. EACH AFFIDAVIT OF WAGES PAID MUST BE CERTIFIED BY THE INDUSTRIAL STATISTICIAN OF THE DEPARTMENT OF LABOR AND INDUSTRIES BEFORE IT IS SUBMITTED TO SAID OFFICER. PROGRESS PAYMENTS:Each voucher claim submitted to an owner by a contractor for payment on a project estimate shall state that prevailing wages have been paid in accordance with the pre• filed statement or statements of intent to pay prevailing wages on file with the public agency. COMPLETE AND MAIL ENTIRE SET FOR APPROVAL TO: Employment Standards Division, Department of Labor and Industries, General Administration Building,Olympia,Washington 98504 LCONTRACTORS. DISTRIBUTE APPROVED STATEMENTS AS FOLLOWS: 1'INs 11GPY1 ORIGINAL-AWARIANG AGENCY HLUF.t'OPY, DUPWCATF.-rE1MF(YINTRACTOR .YELLOW COPY, TRIPLICATE-SURIWNTRWTOR GREEN C0ff) QUADRt'PLICATE-INDILxTRICAI.STATISTICIAR iRwlmd by Ikpaxmmn I.I ne2e loin,1.1'.,I J !W� .66 .ataasGRRd¢ /0[' ..aars...eam+usRl' r 1 t DEPARTMENT OF LABOR AND INDUSTRIES AFFIDAVIT OF WAGES PAID INDUSTRIAL RELATIONS DIVISION Olympkt.WA 985N ON PUBLIC WORKS CONTRACT Awarding Agency City of Rantona Dapt. of Public Works Contract Number CAU015-82. Date Contract Awarded 611182 l6r'ro y;a�PeD ,I Date Contract Completed 8/4/B2 EC D - --- t STATE or WASHINGTON County In Which Work Performed Xing I t, 1gf}9 R, Location within County City of Rantan. 8r COUNTY or Xing.. - Was a Statement of Intent Filed? Yes Q N� iIn compliance with RCW 39.12.040 1, the undersigned, being a duly authorized representative of Red D Pavin4 11728 21st S. N., Seattle, Nash. 90148 do hereby certify that the following rates of hourly wsa a and hourh fri.. a benefits have been g g paid to the laborers, workmen and mechaniev employed by me upon the project described above and that no laborer, workman or mechanic has been paid less than the "prevailing rate of wage" as determined by the Indus- trial Statistician of the Department of Labor and Industries. List below each classification of labor employed by you upon the project described above and the rate of hourly pay and hourly fringe benefits paid to each classification. If apprentices have been employed, list their names and or registration numbers, their stages of progression, the rate of hourly pay and the rate of hourly fringe benefits paid to each apprentice. Craft and Classification of Labor Rate of Rate of Hourly Hourly Pay Fringe Benefits Paid C f7�� : Fa�ti�A( f)%I'JlA[T la �6 .�•prf LRbM'l +f'AkF'� L ylt. ,PA)FI+IF_� 17 •ec.- Non: Attach Additional Sheets w Needed. Red D Paving nbn r Subscribed and sworn to before a By.. �nn<t this day Uf_ .// I hereto cen h that accoedma to the wage man sad fringe teoef n heron sworn to the rrewdmg woe tv tt renott—f RCW 39.12010 have born talot" 19 JOHN DEPARTMENT OF DIRECTOR (^�{^///� ✓ � DEPARTMENT OF IA ND INDUSTRIES olary Pa41te h au the Sea,lof-w'aehinplon. residing h Wwh bet Date._16 DEC,198.2. ._ Br:_.__. This apace reserved for Di or'a rtldcatton INSTRUCTIONS: 1. Pursuant to RCW 39.12.040 copies of this form must be completed by the contractor and each of his sub- contractors. 2. Complete this form in triplicate and have it notarized. 3. Submit all forms for certification to: Industrial Relations Division. Department of Labor and Industries, General Administration Building, Olympia, Washington 98504, 4. File a certified copy with the Awarding Agency. CONTRACTORS ARE RESPONSIBLE FOR OBTAINING AND FILING AFFIDAVITS of the SUB- CONTRACTORS. This is required by law and payments can not lawfully be made until such affidavits are flied. It coo+ ♦pa.w,.t w.F. 1+a, {� J I 1 _ STATE OF NASNI%TON 2UBLIC WORKS CONTRA( DEPARTMENT OF REVENUE RECONCILIATION OF TAXES EXCISE TAX DIVISION OLYWIA, RASNIWTON 485OA C 600 096 431 SEE NASTRUCTIONS TO COMPLETE THIS FORM . Ford Construction Co. P.O. BOX 5036 . Ktnt. WA 98031 City of Renton; i1982 Sanitray Sewer Repair and Pump Station i TAX REPORTED ON SECTION 2 - REGULAR TAX RETURN CTION I - COMPUTATION OF TAX REPORT19G TAM AMNlXT OF TAX CLASSIFICATION TAANLE AMRRIT Ott TAX WE R P 00 C F T TAX R P ED facturl /7 GovrrnM•nt COetractlnq wbilc Road Conttruc"O" Re talilao S / C l"a1 Sale, Ta. Q'a' i -Local Use TAX --- TOTAL TAX WE TOTAL TAX RIIONTED Irrsr F. ECTION O-RECONCILIATION SECTION a- DETAIL OF ROWTANCE ` ty Tu Aut y9 / LINE TAX CLASSIFICATIOR COoF TAXABLE NOW BATE TAX WE Fql SECTION I MOVE). INVS TOT-IJT At ED, 9 M.mXf•ctyrin W46 . STICK 2 A 1) Y III-) 7 — WE Oi TAX 0Y[ IS EMIVQnRMnt EdntrAttlO [N ETE at'lo . IS Public Road CenstmCoo.17 Mullin la19 Use L.11 Lain Sale, To.X2 LKal Use TAX i BALANCE OF TAX 011E AND REMITTED NI TN TNIS REPORT Sales TAX (45) LOCAL CITY AND/OR COUNTY SALES AND USE TAX Use Tax (46) CI Tv DR TAXABLE AMOUNT RATE TAX WE CITY OR TAXABLE AMOUNT t4l CWNTr CODE CITYOR COUNTY COUNTY [OUE TRANSFER TOTA�LTO LIKEE31, SECTION A TRANSFER TOTAL TO LINE 32. SECTI pared BY `.i'. VAlf/ _Ly'. h DATE IL/l Sl Y2' _�— DISTRIBUTION: RETURN ORIGINAL AND ON€CORN, RETAIN PINK COPY FOR YOU0. FILES ` PORN REV 31 0017 (7•92) tC i 1 a Request for Release 0 01 LNor InAwm« iN •Ir•1bnB� Oylp*WA SOW THE UNDERSIGNED CONTRACTOR REQUESTS THAT THE PROPERTY OWNER/GENERAL CONTRACTOR BE NOTIFIED OF THEIR RELEASE FROM LIABILITY FOR INDUSTRIAL INSURANCE PREMIUMS ON THE FOLLOWING WORK— . Ld .� n .f9/L cis kz — /� T o..cr an a Mr. 12 rb •wew+W Cwmp OM wM Yrw Ow wnCwwww h.�.nr 0«wNww�C!i4feM _ — d 750 U T1S_. t 10 1.231 rs Lei o " tn_CV1SIRV�TrON CJ •OMr. O .ft , w C.rr.dr o Ltio� So3o A'enf L+_)n �hF 9i'u j WweSuDtonlnclon uwtll -- --------. r ❑ No m IF YES,ATTACH A LIST SHOWING NAME.ADDRESS,INDUSTRIAL INSURANCE ACCOUNT NO.A'4n NATURE OF WORK PERFORMED. MATERIAL ONLY SUPPLIERS NOT TO BE INCLUDED. WHEN RELE•,SE IS RE- OUESTED BY A SUBCONTRACTOR IT IS UNDERSTOOD THAT ALL WORK WAS PERFORMED BY THE SUB- CONTRACTORS EMPLOYEES, IF WORK PERFORMED BY OTHERS STATE BY WHOM. (ATTACH A LIST SHOWING NAME A ADDRESS) Th.,514KOi"3.G .,rE Ur p. -- - O_T.mmnrr �i s ra �3t 35 Co FoQp-.Cgy s teat ri�,�l_C a K.. JrFM --_-- _y�0�__.�0;3b� Ptnt I�f�usl. SYo3i iL^.,Ir, ALL WORKER HOURS THROUGH THE COMPLETION DATE OF 1 HIS PROJECT MUST HAVE BEEN REPORT 6 PREMIUM PAID BEFORE A RELEASE WILL BE IS3UEO. THIS FORM MUST BE COMPLETED 6 ALL INFORMATION FURNISHED BY PARTY REQUESTING RELEASE, SEND TO DEPARTMENT OF LABOR INDUSTRIES, INDUSTRIAL INSURANCE DIVISION,CONTRACT RELEASE SECTION. OLYMPIA.WA 98504 ,r.iu.r il....0 w 11.irw sr 1 �J tow+,r RECEIVE[) DEPARTMENT OF LABOR AND INDUSTIOypv 19 j982 AFFIDAVIT OF WAGES PAID r INDUSTRIAL RELATIONS DIVISION 1rati'tiii a[G�Ir"fp Olympia.WA 48581 ON PUBLIC WORKS CONTRACT Awarding Agency City of Renton. Dept, of Public works Contract Number. .. Cd0015-82 Date Contract Awarded 6/l/82 Date Contract Completed 10/15/82 .. STATE Or WASHINGTnN County in Which Work Performed King Location within County Cttg of Renton Cou"Y or King _... Was a Statement of Intent Filed? Yes Ik No ❑ ; In compliance with RCW 39,12.040 I, the undersigned, being a duly authorized representative of _ldeal-Lakeside Pump and rquIlm.ant P, O, Box 666, Woodinville, Wash,_98072 �Conrtutor n tu1 Addre�t do hereby certify- that the following rates of hourly ge an r rourly fringe benefits have been paid to the laborers, warkmen and mechanics employed by me upon the project described above and that no laborer, workman or mechanic has been paid less than the "prevailing rate of wage" as determined by the Indus- trial Statistician of the Department of Labor and Industries. List below each classification o' labor employed by you upon the project described above and the rate of t hourly pay and hourly fringe benefits paid to each classification. If apprentices have been employed, list their names and or registration numbers, their stages of progression, the rate of hourly pay and the rate of hourly fringe benefits paid to each apprentice. i. Craft and Classification of Labor Rate of Rate of Hourly i n Hourly Pay Fringe Benefits Paid OWNt1�/S�L..�aM1r _ i��sd 3,�00 i t 0 e , y a f 1 r. Nom Attach Addaiond Shmea es NeM !deal-Lakeside Pwrp and 6gYlpram . Subscribed and sworn to before me By. 01414) J�• i this y day of 'L A'J I Mrtat anar ft,..d,N to tar wW ntn.nd fnge henefw hoe. ec •worn to tM Mrt obNnor reywrtmew.of Rfw W.I taw hot Man 19 JOHN A DEPA f.MENT O LAI R DEPARTMENT lM'LA A!Vn INDUSTRIES 1 Notary it in and for tar Smrr MMM///ArII ael.lnpton. rraldlnp 1.Wwhinpton. 9 1t Mon Hy Thu apace rezerred fm lot rrrUarntlon - a INSTRUCTIONS ; 1. Pursuant to RCW 39.12.040 copies of this form must be completed by the contractor end each of his sub- contractors 2. Complete this form in triplicate and have it notarized. 3. Submit all forms for rectification to: Industrial Relations Division, Department of Labor and Industries, General Administration Building, Olympia, Washington 98504, 4. File a certified copy with llle Awardin8 Agency. CONTRACTORS ARE RESPONSIBLE FOR OBTAINING AND FILING AFFIDAVITS of the SUB- CONTRACTORS. This is required by law and payments can not lawfully be made until such nffidevits are filed. , r1-No, sma.•n w Wyo a-rn 1 RFCEIVEr AFFIDAVITOF* NUS 1? j9R? ON Pl. WORKS CONTRACT DEPARTMENT OF LABOR AND INDUSTRIES INDUSTRIAL.RELATIONS DIVISION Olympia,WA 995g4 Awarding Agency Cit9 of Renton, Public Works Dept. Contract Number _CA0015-82 Date Contract Awarded &&Axx38xx*2JUx R¢rch 8, 1982 Date Contract Completed 1G 23IS2 STATE OF WASIHNGTON County in Which Work Performed .King S. Location within County Renton COUNTY or IS Was a Statement of Intent Filed? Yes L/9 No In compliance with RCW 39.12.040 I, the undersigned, being a duly authorized representative of _.. FORD CONSTRUCTION CO. . I c.o.t.,er 3VUrt.I1.r .rl AGGRVI do hereby certify that the following rates of hourly wage and hourly fringe benefits have been paid to the laborers, workmen and mechanics employed by me upon the project described above and that no laborer, workman or mechanic has been paid less than the "prevailing rate of wage" as determined by the indus. trial Statistician of the Department of Labor and Industries. List below each classification of labor employed by you upon the project described above and the rate of hourly pay and hourly fringe benefits Paid to each classification. Please Note If apprentices have been employed on this project,provide this addition::1 information: name and/or mil tration number and stage of progression. CraN aw ttasnacatloa of I.uhor RYr of Raw of Heady Hourly Pay Fringe Immiles Paid s Laborer - Group 1-e 14.30 1.58 operating Engineer - Group 1 17.61 3.11 Now Attach Adaalonal Sheels As NeMi . D NS RU CQ. . . c A ( /} (/ V�I(A Subscribed and sworn to before me By \P4 f rttta) thla_ladf_.........day of set tae tab I h nth/ ...f,am,a.mmni"to IM aF nor ad fruat heneaa harem 19....�.. 82 srnm to the rmNJiAa NNae rey...r t:of Rt%N 121W A...Ac n sen.6W. L,L3 INDUSTRIAL AN 'IAN Nmarq PVDik In and/o�tae Stole of wool i.grnn. DEPARTMENT OF LABORBOR A NDUSTRIE9 rraidtnq In WwMnptory INSTRUCTIONS: 18 NOV 02 Date: ........... . ... .. RT_.. . L Pursuant to RCW 39.12.040 copies of this form must be completed by the co acio and each o[ is sub- contractors. 2. Complete this form in triplicate and have it notarized. 3. Submit all forms for certification to: Industrial Relations Division, Department of Labor and Industries. General Administration Building, Olympia, Washington 98504. 4. Filea certified copy with the Award' Agency. L CONTRACTORS ARE. RESPONSIBLE FOR OBTAINING AND FILING AFFIDAVITS of the SUB- CONTRACTORS. This is required by law and payments can not lawfully be made until such affidavits are filed. �, I ll-TIa1 \IIiM,il.l N,ye, r�i