Demolition/Abatement Constracts (Folders 1-2)

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~~) (2) (3) DAY AND DATE (4) (5) (6) (7) (8) (9) (10) (1'1) NAME, ADDRE55 AND TRADE, TOTAL BASIC HOURLV HOURLY FRINGE BENEFIT PAID AS GRO55 AMOUNT TOTAL DEDUCTION NET WAGE PAID FOR HOURLV FRINGE BENEFIT PAID TO NAME OF BENEFIT PARTY, PLAN, FUND, SOCIAL SECURITY NUMBER OF EMPLOYEE CIASSIFICATION ~INCLUDE GROU HOURS RATE OF PAY WAGE TO EMPLOYEE EARNED FICA, FED, STATE, ETC. WEEK PARTV, PLAN, FUND OR OR PROGRAM A' IF APPLICABLEI HOURS WORKED EACH DAY PROGRAM OT S OT S OT S OT S CERTIFIED STATEMENT HEREBY STATE: (NAME OF SIGNATORY PARTY) (TITLE) (1) THAT I PAY OR SUPERVISE THE PAYMENT OF THE PERSONS E~.APLOYED BY; ON THE (CONTRACTOR, SUBCONTRACTOR OR SURETY) (BUILDING OR WORK) THAT DURING THE PAYROLL PERIOD COMMENCING ON THE DAY OF , 19 , AND ENDING THE DAY OF , 19_ ALL PERSONS EMPLOYED ON SAID PROJECT HAVE BEEN PAID THE FULL WEEKLY WAGES EARNED, THAT NO REBATES HAVE BEEN OR WILL BE MADE EITHER DIRECTLY OR INDIRECTLY TO OR ON BEHALF OF SAID FROM THE FULL WEEKLY WAGES EARNED BY ANY PERSON, AND THAT NO DEDUCTIONS HAVE BEEN MADE EITHER DIRECTLY OR INDIRECTLY FROM THE FULL WAGES EARNED BY ANY PERSON, OTHER THAN PERMISSIBLE DEDUCTIONS AS SPECIFIED IN ORS 652.610, AND DESCRIBED AS FOLLOWS: (2) THAT ANY PAYROLLS OTHERWISE UNDER THIS CONTRACT REQUIRED TO BE SUBMITTED FOR THE ABOVE PERIOD ARE CORRECT AND COMPLETE; THAT THE WAGE RATES FOR WORKERS CONTAINED THEREIN ARE NOT LESS THAN THE APPLICABLE WAGE RATES CONTAINED IN ANY WAGE DETERMINATION INCORPORATED IN THE CONTRACT; THAT THE CLASSIFICATION SET FORTH THEREIN FOR EACH WORKER CONFORMS WITH WORK PERFORMED. (3) THAT ANY APPRENTICES EMPLOYED IN THE ABOVE PERIOD ARE DULY REGISTERED IN A BONA FIDE APPRENTICESHIP PROGRAM REGISTERED WITH A STATE APPRENTICESHIP AGENCY RECOGNIZED BY THE BUREAU OF APPRENTICESHIP AND TRAINING, UNITED STATES DEPARTMENT OF LABOR, OR IF NO SUCH RECOGNIZED AGENCY EXISTS IN A STATE, ARE REGISTERED WITH THE BUREAU OFAPPRENTICESHIP AND TRAINING, UNITED STATES DEPARTMENT OF LABOR. I HAVE READ THIS CERTIFIED STATEMENT, KNOW THE CONTENTS THEREOF AND IT IS TRUE TO MY KNOWLEDGE. NAME AND TITLE SIGNATURE NOTE TO CONTRACTORS: YOU MUST ATTACH COPIES OF THIS FORM TO EACH OF YOUR PAYROLL SUBMISSIONS ON THIS PROJECT. SEE THE BOLI PUBLICATION PREVAILING WAGE RaTF~ FnR aiiRi ir y~ORKS CONTRACTS IN OREGON FOR INSTRUCTIONS ON COMPLETING THIS FORM. FILE THIS FORM WITH THE CONTRACTING AGENCY ~...,., ~.,~ ~ ~o ~nr~ ~ r_ ~nc~