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~I <br /> PAYROIUCERTIFIEO STATEMENT FORM WH-38 <br /> 6UREAU OF LABOR AND INDUSTRIES FOR USf 1N GOMPLYF#G WITH ORS 279.354 <br /> WAGE AND HOUR DlV15lON <br /> PRIME CONTRACTOR ~ FIRST [~90 DAY ? LAST ? . <br /> SUBCONTRACTOR [ ~ <br /> B,usi~ss Name (D$A): CCB Registration Number: /1373 Project Name: Project Number: <br /> Phone•:~( ) - ,27"~ T e Of Work: ~ <br /> Project Location: <br /> treet Address: /,25'~ ~ ~~r~' <br /> ailing Address: ~ ~ • B`~ ~ .7~7 Project County' <br /> Date Pay Period Bega ~f( Date Pay Period Ended: ~ ~ <br /> THIS SECTION FOR PRIME CONTRACTORS ONLY THIS SECTION FOR SUBCONTRACTORS ONLY <br /> Publ ie Contracting Agency Name: ~ ~,_.c_czf-~*-' Subcontract Amount: <br /> Phone: ( ) C/ Prime Contractor Business Name (DBA); <br /> Date Contract Specifications First Advertised For Bid: /o~ $~fL Phone: ( ) CCB Registration Number: <br /> Contract Amount 2S~ , ~ Date You $e an Work On The Pro'cct: <br /> (1) (2) {3) DAY AND DATE (4) (5) (6) ~ (7) (9) (10) (11) <br /> NAME, ADDRESS AND TRADE, M T G~ TOTAL BASIC HOURLY FRINGE GROSS TOTAL NET WAGE HOURLY FRINGE NAME OF BENEFIT PP <br /> SOCIAL SECURITY GLASSIFICA710N HOURS HOURLY RENEFIT PAID ~ AMOUNT DEDUCTION PAID FOR BENEFIT PAID T PLAN, FUND, OF <br /> NUMBER OF EMPLOYEE (INCLUDE GROUP ~ ~ 1• RATE OF WAGE TO EARNED FICA, FED. WEEK pAg7Y, pLgpl, PROGRAM <br /> x IF APPLICABLE)' PAY EMPLOYEE STATE, ETC FUND OR <br /> HOURS WORKED EACH DAY PROGRAM <br /> z3~x~>;etJ OT ~ <br /> R ~ p v <br /> 9 ' ~ ~ <br /> <br /> ~~r.~.el2/lt'. ~ OT <br /> r~~ S i y~ I ~ ~ <br /> OT <br /> S <br /> OT <br /> S <br /> THIS FORM CONTINUED ON REVERSE <br /> cnonn tntt-I_4R (REV. 6/961 <br /> <br />