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6UREAU OF LABOR AND INDUSTRIES PAYROLL/CEATIFIED STATEMENT FOAM WH-3B <br /> WAGE AND HOUR DIVISION FOR USEttJ t'OktPIYING WITH ORS 279.354 <br /> PRIME CONTRACTOR FIRST ? 90 DAY ? LAST ~ ~ <br /> SUBCONTRACTOR ? j, <br /> Business Name (DBA): CCB Registration Number: /1.~3f <br /> 7Ja Project Name: Project Number: <br /> Phone: (,S'Sl/) y~ - ~ T e Of Work: <br /> Street Address: Project Location: <br /> ailing Address: Project County: <br /> Date Pay Period Began: Date Pay Period Ended: <br /> THIS SECTION FOR PRIME CONTRACTORS ONLY THIS SECTION FOR SUBCONTRACTORS ONLY <br /> Public Contracting Agency Name: ~~A ~ Subcontract Amount: <br /> Phone: ( ) ~ G / Prime Contractor Business Name (DBA): <br /> Date Contract Specifications First Advertised For Bid: /D ~$'09~ Phone: ( ) CCB Registration Number: <br /> Contract Amount 2$z4 . ~ ~ ~ Date You Be an Work On The Pro'ect: <br /> {1} (2) <br /> (3) DAY AND DATE (d) (5) (6) (T} (8) (9} {10) (11) <br /> NAME, ADDRESS AND TRADE, s t~ % / F s TOTAL BASIC HOURLY FRINGE GAOSS TOTAL NET WAGE yOURLY FRINGE NAME OF BEtJEFrT PA <br /> SOCIAL SECURITY CLASSIFICATION HOURS HOURLY BENEFIT PAID AS AMOUNT DEDUCTION PAID FOR BENEFIT PAID T PLAN, FUND, OR <br /> NUMBEA OF EMPLOYEE tINCIUDE GROUP 5 G L WAGE TO EARNEp FICA, FED, WEEK <br /> x IF APPLICABLE)' 9 /6 / RATE OF EMPLOYEE STATE, ETC PARTY, PLAN, PROGRAM <br /> PAY FUND OR <br /> HOURS WORKED EACH DAY PROGRAM <br /> OT <br /> 5 ti~ ova <br /> <br /> ~a-`-ems ~ ~ OT <br /> ~ ~ ,3 <br /> l,~°' S ~ <br /> I~ I <br /> OT <br /> S <br /> OT <br /> S <br /> THIS FORM CONTINI~ED ON REVERSE <br /> Gnann WH-38 (REV, 6/96) <br /> <br />