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Bureau of Labor and Industries <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 CONTRACT FEE INFORMATION 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 contract price* ) payable to BOLI. MINIMUM FEE IS $100.00, MAXIMUM FEE IS <br />$5,000.00. Without the following completed information, the bureau may be unable to properly credit you <br />for payment received. <br />BUSINESS NAME (DBA) <br />MAILING ADDRESS: <br />PROJECT NAME: <br />PROJECT NUMBER: <br />AGEN~Y AWARDING CONTRACT: <br />AGENCY CONTACT PERSON: <br />CONTRACT AMOUNT: <br />*(Contract amount X .001) <br />DATE AWARDED: <br />PHONE: ( 1 <br />DATE WORK BEGAN: <br />(Please duplicate this form for future use) <br />CCB # <br />PHONE: ( ) <br />PROJECT LOCATION: <br />(STREET OR PU BOX #~ <br />(CITY, STATE, ZIP) <br />1?J95197(ee(msam <br />