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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 For Office Use Only: <br />Project DB # <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 BOLT The <br />minimum fee is S250.00, the maximum fee is 57,500.00. Without the following completed information, the <br />bureau may be unable to properly credit you for payment received <br />PUBLIC AGENCY: Cav of Eugene - Enameenng AGENCY 1336 <br />AGENCY MAILING ADDRESS: 99 E Broadwav Suite 400 <br />CITY, STATE, ZIP: Eugene. OR 97401 <br />AGENCY CONTACT PERSON: Lvnn Broaden PHONE: 541-682-5238 <br />PROJECT MANAGER NAME: Doug Singer PHONE 541-682-8460 <br />PROJECT NAME: Pavement Preservation Program -2010 Local Street Rears <br />CONTRACT NAME (if part of larger project): <br />PROJECT LOCATION: Various locations in the city <br />PROJECT NO: 4686 (Contract 82010-25) DATE CONTRACT FIRST ADVERTISED: 4/20/2010 <br />DATE CONTRACT AWARDED 05/28/2010 CONTRACTOR CCB#: 126290 <br />CONTRACTOR BUSINESS NAME (DBA): McKenzie Excavating Inc <br />CONTRACTOR ADDRESS: 28568 Bodenhamer Road <br />ICU 201 1 <br />CITY, STATE, ZIP: Eugene. OR 97402 <br />o~ <br />CONTRACT AMOUNT: S144,981 96 FEE AMOUNT DUE/PAID: 5ft. - <br />If less than 550K, is it part of a larger project? ❑yes ❑no Contract amount x .001 = fee due <br />(Please duplicate this form for future use) <br />3q,a - ~33Z-(c I.94A - 905'50L' <br />WH-39 (Rev 03/09) SCANN D(-pQ <br />Wq <br />DATE: e <br />INITIALS. <br />