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1 ~ 2 3 :DAYANp:DA]'E ~ • = 4 5 ~ 6 ~ 8 j:`r~'>.-': 9' 10 11 <br /> URL RLY F NG ' <br /> NAME AND ADDRESS OF TRADE, BASIC FRINGE TOTAL NET BENEFITS PAID <br /> EMPLOYEE CLASSIFICATION TOTAL HOURLY BENEFIT GROSS DEDUCTIONS WAGES TO BENEFlT NAME OF BENEFlT PARTY, <br /> IlNCLUDE GROUP HOURS RATE OF AMOUNT PAID AMOUNT FICA, FED, PAID FOR PARTY, PLAN, PU4N, FUND, OR PROGRAM <br /> K IF APPLICABLE) PAY A8 WAGES TO EARNED STATE, ETC. WEEK FUND OR <br /> HOURS WORKED EACH DAY EMPLOYEE PROGRAM <br /> OT <br /> S <br /> OT <br /> S <br /> OT <br /> S <br /> CERTIFIED STATEMENT <br /> h6ke Amehms Secretary/Treasurer <br /> I, DO HEREBY STATE: <br /> (NAME OF SIGNATORY PAR ) (TITL) <br /> (7) THAT !PAY OR SUPERVISE THE PAYMENT OF THE PERSONS EMPLOYED 8Y: iPacMic Envirommental Group, hc. ON THE ' CItY of Eugene Warehouse ` <br /> fb (CONTRACTOR, SUBCONTRACTOR OR SURETY) (BUILDING OR WORK) <br /> THAT DURING THE PAYROLL PERIOD COMMENCING ON THE ~ DAY OF ~P~ bP_i" AND ENDING THE 2~ st DAY OF _,~c_fab cr _ ~ <br /> (MONTH) ~ (YEAR) (MONTH) ~ (YEAR) <br /> ALl PERSONS EMPLOYED ON SAID PROJECT HAVE BEEN PAID THE FULL WEEKLY WAGES EARNED, THAT NO REBATES HAVE BEEN OR WILL 8E MADE EITHER DIRECTLY OR INDIRECTLY TO OR ON BEHALF OF <br /> SAID ;Pacific Envkonmental Group, Inc. FROM THE FULL WEEKLY WAGES EARNED BY ANY PERSON, AND THAT NO DEDUCTION3 HAVE BEEN MADE EITHER DIRECTLY OR INDIRECTLY FROM THE FULL <br /> WAGES EARNED BY ANY PERSON, OTHER THAN PERMISSIBLE DEDUCTIONS AS SPECIFIED IN ORS 652.810, AND DESCRIBED AS FOLLOWS: <br /> eA~- _ _ _ <br /> {2) THAT ANY PAYROLLS OTHERWISE UNDER THIS CONTRACT REQUIRED TO BE SUBMITTED FOR THE A80VE PERIOD ARE CORRECT AND COMPLETE; THAT THE WAGE RATES FOR WORKERS CONTAINED <br /> <br /> THEREIN ARE NOT LESS THAN THE APPLICABLE WAGE RATES CONTAINED IN ANY WAGE DETERMINATION INCORPORATED IN THE CONTRACT; THAT THE CIASSIFiCATION SET FORTH THEREIN FOR EACH <br /> <br /> WORIfER CONFORMS WITH WORK PERFORMED. <br /> <br /> (9) 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 <br /> 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 <br /> OF <br /> <br /> APPRENTICESHIP AND TRAINING, UNITED STATES DEPARTMENT OF LABOR. <br /> i HAVE READ THIS CERTIFIED STATEMENT, KNOW THE CONTENTS THEREOF AND IT IS TRUE TO MY KNOWLEDGE. <br /> Mace Amedns Secretary/Treasurer i-^ <br /> NAME AND TITLE 6 SIGNA~i <br /> NOTE TO CCLNTRACTORS: YOU MUST ATTACH COPIES OF THIS FORM TO EACH OF YOUR PAYROLL SUBMISSIONS ON THIS PROJECT. SEE THE SOLI PUBLICATION PREVAILING WAGE RATES FOR PUBLIC WORKS <br /> CONTRACTS IN OREGON FOR INSTRUCTIONS ON COMPLETING THIS FORM. <br /> FILE THIS FORM WITH THE CONTRACTING AGENCY <br /> FORM WHa38 (REV. 8/99) <br /> <br />