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12~2vI o 6113'&/ a l l~ <br />-ru P <br />CONTRACT FEE SECTION <br />PREVAILING WAGE RATE UNIT <br />BUREAU OF LABOR AND INDUSTRIES <br />800 N.E. OREGON ST., #1045 <br />PORTLAND, OR 97232-2180 <br />PHONE: (971) 673-0852 <br />FAX: (971) 673-0769 H'or Office Use 0111y: <br />PUBLIC WORKS FEE INFORMATION FORM <br />For use by public agencies that have contracted with a contractor on a public works project regulated by <br />ORS 279C.800 to 279C.870, in compliance with ORS 279C.825. Also for use by public agencies that are a <br />party to a public works project pursuant to ORS 279C.800(6)(a)(B) or (C). <br />PUBLIC AGENCIES: Please complete and mail this form to BOLI at the above address, along with the public <br />works fee of one-tenth of one percent of the contract price (contract amount x .001), payable to BOLL The <br />minimum fee is $250.00; the maximum fee is $7,500.00. Without the following completed information, the <br />bureau may be unable to properly credit you for payment received. <br />PUBLIC AGENCY: City ooEugene-Engineering AGENCY 1336 <br />AGENCY MAILING ADDRESS: 99 E. Broadway, Suite 400 <br />CITY, STATE, ZIP: Eugene, OR 97401 <br />AGENCY CONTACT PERSON: Lynn Bro den PHONE: 541-682-5238 <br />PROJECT MANAGER NAME: Terry Colvin PHONE: 541-682-5398 <br />PROJECT NAME: 2010 Stormwater Rehabilitation <br />CONTRACT NAME (if part of larger project): <br />PROJECT LOCATION: On 15d' Avenue from Agate Street to Moss Street and at the intersection 17`t' Avenue and <br />PROJECT NO: 4671 DATE CONTRACT FIRST ADVERTISED: 04/20/2010 <br />DATE CONTRACT AWARDED: 05/14/2010 CONTRACTOR CCB#: 52470 <br />CONTRACTOR BUSINESS NAME (DBA): Kipco, Inc. <br />CONTRACTOR ADDRESS: 90465 Woodruff Street <br />CITY, STATE, ZIP: Eugene, OR 97402 <br />ov <br />CONTRACT AMOUNT: $120,195.00 FEE AMOUNT DUE/PAID:O. <br />If less than $50K, is it part of a larger project? ❑yes ❑no Contract amount x .001 = fee due <br />(Please duplicate this form for future use) <br />X31- 9332-~ ~g~~ -dos 1~~ <br />WH-39 (Rev. 03/09) <br />