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Bureau of Labor and [ndustries <br />Prevailing Wage Rate Unit <br />800 N.E. Oregon St., # 32 <br />Portland, OR 97232 <br />Phone: (503) 731-4074, Fax: (503) 731-4623 <br />=PUBLIC WORK GONTRACT FE~ INFORIVLATION FORM <br />(For use by contractors in complying with ORS 279.375) <br />THIS FORM TO BE USED FOR PROJECTS AWARDED AFTER SEPTEMBER 9,1995 ONLY <br />Contractors: Please complete and mail this form to BOLI at the above address, along with the appropriate fee <br />(1/lOth of 1% of the contra~t price* ) payable to BOLI. MINIMUM FEE IS $100.00, MAXIMUM FEE IS <br />S5,000.00. W ithout the following completed information, the bureau may be unable to properly credit you for <br />payment received. ~ <br />BUSINESS NAME (DBA) <br />MAILING ADDRESS: <br />PROJECT NAME: <br />(STREET OR PO BOX 1~~ <br />(CITY, STATE, ZIP) <br />CCB # <br />PHONE: ( ) <br />PROJECT NUMBER: <br />AGENCY AWARDING CONTRACT: <br />AGENCY CONTAGT PERSON: <br />CONTRACT AMOUNT: <br />•(Contract amount X .001) <br />PROJECT LOCATION: <br />DATE AWARDED: <br />PHONE: ( .~ . <br />DATE WORK BEGAN: <br />(Please duplicate thia form for future use) <br />17/95199fadm.wn <br />