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CONTRACT FEE SECTION <br />PREVAILING WAGE RATE UNIT <br />BUREAU OF LABOR AND INDUSTRIES <br />800 N.E. OREGON ST., 41045 <br />PORTLAND, OR 97232-2180 <br />PHONE: (971) 673-0852 <br />FAX: (971) 673-0769 <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 of Eu eng a Engineering AGENCY 1336 <br />AGENCY MAILING ADDRESS: 99 E. Broadway. Suite 400 <br />CITY, STATE, ZIP: Eugene. OR 97401 <br />AGENCY CONTACT PERSON: Lynn Brogden PHONE: 541-682-5238 <br />PROJECT MANAGER NAME: Doug Singer PHONE: 541-682-8460 <br />PROJECT NAME: Pavement Preservation Program - 2010 Slurry Seals Project at various locations <br />CONTRACT NAME (if part of larger project): <br />PROJECT LOCATION: Various locations in Eugene <br />PROJECT NO: 4663 DATE CONTRACT FIRST ADVERTISED: 5/14/2010 <br />DATE CONTRACT AWARDED: 0705/2010 CONTRACTOR CCB#: 62952 <br />CONTRACTOR BUSINESS NAME (DBA): Asphalt Maintenance Associates. Inc <br />CONTRACTOR ADDRESS: 2080 Prairie Road <br />CITY, STATE, ZIP: Eugene. OR 97402 <br />CONTRACT AMOUNT: $346.797.74 FEE AMOUNT DUE/PAID: 3q (o. E <br />If less than $50K, is it part of a larger project? ❑yes ❑uo Contract amount x .001 = fee due <br />(Please duplicate this form for future use) (>CJI 3~3 <br />-642-~337 -(,I9&y- 96 <br />S/~~ <br />WH-39 (Rev. 03/09) <br />5CANNED (TWA <br />DATE: <br />INITIALS: <br />