SMALL WORKS |
STATEMENT OF INTENT TO |
PUBLIC WORKS CONTRACT |
PAY PREVAILING WAGES |
($2,500 or less including tax) |
AND |
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AFFIDAVIT OF WAGES PAID |
This form must be typed or printed in ink and completed in full or it will be returned for correction. Large, bold numbers match instructions on the back of this form. Shaded areas are for the Awarding Agency and Labor &Industries (L&I) use only.
Contractors may obtain this form from the CONTRACT AWARDING AGENCY only. Contractors must complete and return the form to the CONTRACT AWARDING AGENCY. If the agency approves the form, it will send a copy of the approved form to L&I within 30 days of the date the agency received the form from the contractor.
1 Contract Awarding Agency |
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Project Name |
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Awarding Agency Address |
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Contract or Purchase Order Number |
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City |
State |
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ZIP+4 |
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County Where Work Was Performed |
City Where Work Was Performed |
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Indicate Total Dollar Amount of Your Contract - Include Sales Tax |
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Date Contract Awarded (mm/dd/yy) |
Date Work Completed (mm/dd/yy) |
(No “Time & Materials” allowed) |
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$ |
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2 Number of Owner/Operators who own at least 30% of the company who performed work |
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on this project: (check one box) |
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None (0) |
One (1) |
Two (2) |
Three (3) |
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3 Did employees perform work on this project? |
(check one box) |
Yes |
No (If “Yes” - please list below) |
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Crafts/Trades/Occupations and Apprentices – For Apprentices enter the name, registration number, trade, dates worked on project, stage of progression, wage and usual benefit for each apprentice.
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Number
of Workers
in Each Trade
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Total # of
Hours Worked
in Each Trade
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Rate of Hourly
Usual (“Fringe”)
Benefits
9Contractor Company Name
Contractor Phone Number
Contractor Address
Contractor Email Address |
City |
State |
ZIP+4 |
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Contractor Registration Number
Contractor Industrial Insurance Account Number
I hereby certify that the above information is correct and that all workers I employed on this Public Works Project were paid no less than the Prevailing Wage rate(s) as determined by the Industrial Statistician of the Department of Labor & Industries. I understand that contractors who violate Prevailing Wage laws, e.g., apply incorrect classifications/scopes of work for tasks performed on the project, fail to pay correct prevailing wage rates, etc., are subject to fines and/or debarment and will be required to pay any back wages due workers. See RCW 39.12.065.
PLEASE NOTE:
•In approving this form, the Awarding Agency must verify that the Contractor’s Registration or License is current and valid.
•The contract dollar amount indicated shall only be for a single payment in full on a single contract with the Awarding Agency. NO subcontractors.
•For information on potential Awarding Agency liability regarding use of this alternate filing process, see RCW 39.12.040(2)(d).
•RCW 39.12.040(2)(e): Nothing in this section shall be interpreted to allow an Awarding Agency to subdivide any public works project of more than two thousand five hundred dollars for the purpose of circumventing the procedures required by RCW 39.12.040(1).
10Approval: Name and Title of Individual Authorized to Approve This Form on Behalf of the Awarding Agency (type or print)
Signature of Individual Authorized to Approve This Form on Behalf of the Awarding Agency
Received: Department of Labor & Industries
Date: __________________________________________
F700-106-000 Combined Intent & Affidavit – Small Works – ($2,500 or less) 09-2010
INSTRUCTIONS FOR COMPLETING THE
STATEMENT OF INTENT TO PAY PREVAILING WAGES AND AFFIDAVIT OF WAGES PAID FORM
FOR SMALL WORKS PUBLIC WORKS CONTRACTS $2,500 OR LESS, INCLUDING TAX
Contractors: Please submit this form to the CONTRACT AWARDING AGENCY, not to Labor & Industries.
NOTE: Numbers on instructions match the large bold numbers on the front of this form.
1.Contract Awarding Agency – This is the name of the public agency that awarded the contract. Awarding agencies that are not public agencies (i.e., non-profit awarding agencies) cannot authorize use of this form.
Address, City, State, ZIP +4 – This is the address of the contract awarding agency. Project Name – This is the name of the project.
Contract or Purchase Order Number– This is the number of the contract or purchase order assigned by the awarding agency. County where work was performed – This is the county in which the actual work was performed.
City where work was performed – This is the city in which the work was performed. If the work was performed outside the limits of any city, write “N/A” in this space.
Indicate Total Dollar Amount of Your Contract – Include sales tax. Be sure to list the actual total dollar amount, not “Time & Materials” or “T&M”.
Date Contract Awarded – This is the date the contract was awarded to the contractor by the awarding agency. (month/day/year) Date Work Completed – This is the date you completed work on the project. (month/day/year)
2.Number of owner/operators who performed work on the project and own 30% or more of the company – Please indicate the number of owner/partners who performed work on this project. Individuals who own less than 30% of the company are not considered owners/operators, and must be paid prevailing wage rates.
3.Did Employees Perform Work on this Project – Please indicate “yes” or “no”. If “no”, you do not need to fill in the crafts/trades/occupations section below.
4.Crafts/Trades/Occupation – List each craft/trade/occupation of workers employed on this project. If this is residential, landscape, or underground sewer and water construction, please state that on the form. If operating engineers and/or truck drivers were used, describe the type, and list the size or rated capacity of the equipment. If you indicated any owners/partners in the question above AND you also indicated no employees, you do not need to fill in this section.
Apprentices – If apprentices were employed on this project, list each by name, registration number, craft, stage of progression, beginning and ending dates of work performed on this project, and rate of hourly pay and fringe benefits. Any workers not registered with the Washington State Apprenticeship and Training Council must be paid prevailing journey-level wages. Any apprentice not registered with the Washington State Apprenticeship and Training Council within 60 days of hiring must be paid prevailing journey-level wages for the time preceding the date of registration. To verify apprenticeship registration and status, call (360) 902-5324.
5.Number of Workers – List the number of journey-level workers employed for each craft/trade/occupation on this project.
6.Total Number of Hours Worked – List the total number of hours worked for each craft/trade/occupation.
7.Rate of Hourly Pay – Enter the rate of hourly pay for each craft/trade/occupation. This is the wage you actually paid to the workers.
8.Rate of Hourly Usual Benefits – Enter the rate of hourly usual benefits. This is the cost of “usual benefits” (as defined by WAC 296-127-014 and RCW 39.12.010) that you actually provided to the workers. The amount listed for “Rate of Hourly Pay” plus the amount listed for “Rate of Hourly Usual Benefits” (if any) must equal or exceed the prevailing rate of wage.
9.Company Name (Contractor working directly for the Awarding Agency only. Subcontractors cannot use this form.) – Indicate your company’s name, address, phone number, and the signature of an authorized company representative with date signed. (Your contractor registration number begins with the first letters of company name).
10.Awarding Agency Approval – Indicate the date the form is approved, and enter the name, phone number, signature, and title of the awarding agency’s authorized representative.
Within 30 days of receipt this form from the contractor,
the Awarding Agency must send a copy of the approved form to:
Prevailing Wage Program
PO Box 44540
Olympia, WA 98504-4540
F700-106-000 Combined Intent & Affidavit – Small Works – ($2,500 or less) 09-2010
