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BUREAU OF LABOR AND INDUSTRIES <br />NOTICE OF AWARD OF PUBLIC WORKS CONTRACT <br />(For usc by Public Agencies in Complying with ORS 279.363) <br />1.CONTRACTING AGENCY INFORMATION <br />Name <br />taddress _ <br />City, State, Zip <br />Agency Representative <br />2. CONTRACT INFORMATION <br />Project Name <br />Project Manager Name <br />Agency Numbcr <br />Phone <br />Project Number <br />Fax Number <br />Phone Number _ _ ___ <br />Project Location (Street(s), City, State) _ _ _ <br />Project County __ ____ __ _ Contract Amount_ _ . <br />Source of Funds (i.e. 100% Federal Funds, 50150 Federal/State, 100% Local, etc.) <br />Note: If this project is Federally funded and subject to the Davis Bacon Act, do not submit this <br />form to the Oregon Bureau of Labor and Industries. If Fedcral funds are involved, but the projec <br />is subject to Oregon prevailing wage rate, please specify. <br />Date Contract Specifications First Advertised for Bid _ ._ <br />Date Contract Awarded _ Date Work Expected to Begin <br />Date First Progress Payment Due Expected Date of Completion_ <br />3. PRIME CONTRACTOR INFORMATION <br />Name _ <br />__ _ _ _ <br />Address __ <br />_ __ . _ <br />City, State, Zip_ _ Phone <br />Construction Contractors Board Registration Number <br />Workers' Comp. Insurance Company <br />Workcrs' Comp Policy/Binder Number __ <br />THIS FORM WILL BE RETURNED TO THE CONTRACTING AGENCY FOR <br />CORRECTION AND RESUBMITTAL IF INCOMPLETE. <br />RETURN THIS COMPLETED FORM TCX Burcau of Labor and Industries <br />Wage and Hour Division Rm 1160 <br />Prevailing Wage Section <br />8OO NE OREGON # 32 <br />PORTLAND~ OR 97232 <br />(503) 731-4074, exr. 250 Fax: (503)731-4623 <br />g:Awhd\pwrAbidaward.sam(Rcv. G/')6) <br />wH-s~ <br />