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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 For Office Use Only: Project DB #:_____________ 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 The works fee of one-tenth of one percent of the contract price (contract amount x .001), payable to BOLI. 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: AGENCY #: City of Eugene 1336 AGENCY MAILING ADDRESS: 99 E. Broadway, Suite 400 CITY, STATE, ZIP: Eugene, OR 97401 AGENCY CONTACT PERSON: PHONE: Lynn Brogden 541-682-5238 PROJECT MANAGER NAME:PHONE: Adam Steffen 541-682-5040 PROJECT NAME: Delta ponds Area 5 Channel Construction CONTRACT NAME (if part of larger project): No PROJECT LOCATION: Delta Ponds Area 5 Channel PROJECT NO: DATE CONTRACT FIRST ADVERTISED: 4723 6/28/2011 DATE CONTRACT AWARDED: CONTRACTOR CCB#: 8/15/2011 192675 CONTRACTOR BUSINESS NAME (DBA): Rexius Forrest By Products CONTRACTOR ADDRESS: 1275 Bailey Hill Road CITY, STATE, ZIP: Eugene, OR 97402 CONTRACT AMOUNT: $ FEE AMOUNT DUE/PAID: 99,848.91 250.00 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) WH-39 (Rev. 03/09)