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CONTRACT FEE SECTION PREVAILING WAGE RATE UNIT BUREAU OF LABOR AND INDUSTRIES 800 N.E. OREGON ST, #1045 PORTLAND, OR 97232-2180 PHONE (971) 673-0852 FAX: (971) 673-0769 Etir,-Office UsetOnly;_ Project DB il i` PUBLIC WORKS FEE INFORMATION FORM For use by public agencies that have contracted with a contractor on a public works project regulated by ORS 279C.800 to 279C.870, in compliance with ORS 279C.825. Also for use by public agencies that are a party to a public works project pursuant to ORS 279C 800(6)(a)(B) or (C). PUBLIC AGENCIES: Please complete and mail this form to BOLI at the above address. along with the public works fee of one-tenth of one percent of the contract price (contract amount x 001), payable to BOLI The minimum fee is $250.00; the maximum fee is $7,500.00. Without the following completed information, the bureau may be unable to properly credit you for payment received PUBLIC AGENCY: City of Eugene - Engineering AGENCY 1336 AGENCY MAILING ADDRESS: 99 E Broadwav Suite 400 CITY, STATE, ZIP: Eugene, OR 97401 AGENCY CONTACT PERSON: Lvnn Brogden PHONE: 541-682-5238 PROJECT MANAGER NAME: David Starns PHONE: 541-682-8306 PROJECT NAME: 2010 Wastewater Rehabilitation at various locations CONTRACT NAME (if part of larger project): PROJECT LOCATION: Various locations in the city PROJECT NO: Job #4589 (Contract #2010-21) DATE CONTRACT FIRST ADVERTISED: 3125/2010 DATE CONTRACT AWARDED: 06108i2010 CONTRACTOR CCB#: 88084 CONTRACTOR BUSINESS NAME (DBA): H & J Construction, Inc CONTRACTOR ADDRESS: PO Box 2432 CITY, STATE, ZIP- Eugene, OR 97402 2Or't~t`~~y95 CONTRACT AMOUNT* 5555.703 00 FEE AMOUNT DUE/PAID: 555,70 If less than $50K, is it part of a larger project? ❑yes ❑no Contract amount x .001 = fee due (Please duplicate this form for future use) 532' 933 Z - &I -31,0q - 965 //5 WH-3,9 (Rev 01:09)