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BUREAU VF LABOR AND INOUSTRtES PAYRDLLICERIIFIEDSTAIEMENT FORM VN1.7B <br /> WAGE AND HOUR DIVISION FOR USE IN COI~LYING WITH ORS 279.35A <br /> PRIME CONTRACTOR ? Check one: FIRST ? 90 DAY ? LAST O - <br /> <br /> SUBCONTRACTOR ? <br /> Business Name (DBA): CCB Registration Number: 66770 Project Name: ;pty of Eusene Warehouse Project Number: <br /> PACFiC ENVIRONMENTAL GROUP, EJC. I <br /> i <br /> Phone: (5411 767-3770 T e of Work: ASBESTOS REMOVAL <br /> Street Address: Project Location: i3o1 LNxoln st. Euselle, oR <br /> PO BOX 22306 EUUGENE, OR 97402 (Lane County <br /> Mailing Address: Project County. <br /> Gate Pay Period Began: /d /9 Gy Date Pay Period Ended: ~p ,Z/ Qy <br /> THIS SECTION FOR PRIME CONTRACTORS ONLY THIS SECTION FOR SUBCONTRACTORS ONLY <br /> Public Contracting Agency Name: Subcontract Amount: <br /> Phone: ( ) CCB Registration Number: Prime Contractor Business Name (DBA?: <br /> Date Contract Speciiicatfans First Advertised For Bid: Phone: ( ) CCB Registration Number: <br /> Contract Amount: Date You Be an Work On The Pro act: <br /> (1) (2) (3) DAY ANU DATE 4 5 6 7 8) 9 (10 11 j <br /> Y Y <br /> tRAOE, ~Q ~Q BASIC FRINGE TOTAL NET FRINGE <br /> NAME ANO AGGRESS OF CLASSIFICATION 70TAL HOURLY BENEFIT GROSS DEDUCTIONS WAGES BENEFITS PAID NAME OF BENEFIT PARTY, <br /> EMPLOYEE tiNCIUDE CROUP HOURS MTE OF AMOUNT PAID AMOUNT FICA, FED, PAID fOR TO BENEFIT PLAN, FUND, OR PROGRAM <br /> M IF APPLICABLE) ~ 9 ,ZO .Z! PAY Aa WAGES TO EARNED STATE, ETC, WEEK PARTY, PLAN, <br /> HOURS WORKED EACH OAY EMPLOYEE FUND OR <br /> PROGRAM <br /> William Wiese OT ,3,3.79 9, (as <br /> 41269 McKenzie Hwy GROUP 3 <br /> Sprlndfield, OR 97478 LABORER <br /> 540-62-4896 <br /> s . ~ 5 !3 ,2,2.E 9 • ~°5 '~1~.3~ ly6 • Z71. y~ <br /> Steven Ward OT - ,33.79 9, 4J - - <br /> 41269 McKerizk HWY GROUP 3 <br /> 5prinsfkld. OR 97478 LABORt.R <br /> 540-94-0931 <br /> S BIZ • ~O~Z ~z.03 9.fo5 za9,i7 73,so 135.97 <br /> Alfred <br /> 2881a Lasso Ln. 33 , 79 C~, b5 - <br /> Jurletlon CItY. OR 97448 OT <br /> 530-46-02006 GROUP 3 <br /> LABORER <br /> S 5 ~ .Z,Z.•`~ 9.(05 1lo0.go ry5,05 !lS.eS <br /> 3 74 9. <br /> 703 D~ra4~ Sectlon Rd OT _ 3. ~o rJ - - - <br /> Drab, OR 97435 GROUP 3 <br /> 540-68-0656 LABORER <br /> S 5 ~ ,ZZ• 53 9. ~ s z89.~~ 8~ , sg zaz, <br /> Bsrbsra Bearden OT - ,3',3. 79 9. (0 5 - - - <br /> 46 Roys1 ,fie. GROUP 3 <br /> E5u4s~68 402 LABORER <br /> s 5~z 5l~ ,Z,Z.~ q. ~s i,~(0.99 ,94 115.os <br /> THIS FORM CON i D ON REVERSE <br /> <br />