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i <br /> o F o CONTRACT FEE SECTION <br /> ~Fi 'Q~ PREVAILING WAGE RATE UNIT <br /> BUREAU OF LABOR AND INDUSTRIES <br /> ,I F" ~ - : ~ 800 N.E, OREGON ST., #1045 <br /> N - ~ Z PORTLAND, OR 97232-2180 _ <br /> II PHONE: (971) 673-0852 <br /> +~4. <br /> lgr~g FAX: (971) 673-0769 1<or Office Ilse Only°: <br /> Project T~f3'i: <br /> <br /> i <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 BOLI. 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 Eugene -Engineering AGENCY 1336 <br /> AGENCY MAILING ADDRESS: 99 E. Broadway <br /> CITY, STATE, ZIP: Eugene, OR 97401 <br /> AGENCY CONTACT PERSON: Lynn Bro,gden PHONE: (541) 682-5238 <br /> PROJECT MANAGER NAME: Doug Singer PHONE: (541)682-8460 <br /> PROJECT NAME: PBM Amazon Path Rehabilitation Project from 19`~ Avenue to 315` Avenue <br /> CONTRACT NAME (if part of larger project): <br /> I <br /> PROJECT LOCATION: Amazon Path from 19~' Avenue to 315f Avenue <br /> PROJECT NO: 4602 DATE CONTRACT FIRST ADVERTISED: 5/19/2009 <br /> DATE CONTRACT AWARDED: July 26, 2009 CONTRACTOR CCB#: 166194 <br /> . CONTRACTOR BUSINESS NAME (DBA): KSH Construction Co. <br /> CONTRACTOR ADDRESS: PO Box 21431 <br /> CITY, STATE, ZIP: Keizer OR 97307 <br /> CONTRACT AMOUNT: $366,366.00 FEE AMOUNT DUE/PAID: $29.99 <br /> If less than $SOK, is it part of a larger project? ?yes ?no Contract amount x .001 =fee due <br /> (Please duplicate this form for future use) <br /> 'off p(~ ®®I I~ <br /> WH-39 (Rev. 03/09) /A°33 0 <br /> ~6~~®q "tt 5~1~ <br /> 3 <br /> _ _ _ _ _ <br /> <br />