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Bureau oL Labor and Industries <br />Prevailinq Wage Rate UniL <br />800 N.E. Oregon St=. , ## 3`l <br />Portland, OR 97?,32 . <br />E:~}ic~ne: (503) 731-4074, ext.~?50 <br />FAX: (503) 731-9G23 ' <br />~'~~I~~l4RKS CONTRA~~'~E AvDJUaTMENT FS~~M <br />THIS FORM TO BE USI;D FOR RECONCILIATION OF FEES ON COMPLETION OF <br />PUBLIC WORKS PROJECTS <br />(As re~yuired by ORS 279.375 an~~ i)AP H39 7G 2]0) <br />S~9t1t~Zs~S~L41~~~ Vlease compleCe and mail Lhis form t_o [iOLl aC the above addrees, afcc,r <br />complet.ion ot thF~ public wc~rks projecY and uoL less than 30 days aftec thc fina] <br />paymenL by the conlractinq age.ncy. Cont_ractors are required Lo determine ~he iinal <br />contract price, includinq all chanqe ozders c~r other adjustments to Che oric~ina] <br />contract price and to calculate the ad;justed prevailing wage rate fee, based on Lt~f• <br />revised contract price. C~ocumentation must be i~cluded Co support the final conCracr <br />price. The prevailinq wage rate fee, .001, (1/lOth of lt) shal.l be applied ta t.he- <br />final contract price, with credit taken for fees already submitted. The contractox <br />musC submit the additiona] Lee payable to 130LI with the adjustment form c~r requests <br />for refund if applicabl_e. ~O A.UDITIO~AL FE~ W~LL B~ CHARG~D, NOR_1~ <br />R~FUNI) MADE, ON ANX R~CONCILED AMOUNTS UNDER 5100 OQ <br />BUSINESS NA2+iE (DBA) <br />MAILING ADDRESS: <br />PROJECT NAME: <br />(STREET OR PO BOX #, CITY, STATE, ZIP) <br />PROJfiCT NLIMBER: PROJECT LOCATION: <br />AGENCY AWARDING CONTRACT: <br />ccs # <br />HONE : ~---.__~_.___----------__ _____ <br />DATE AWARDED: <br />FINAL CONTRACT AMOUNT: FINAL FEE DUE*: <br />_ _ <br />_ __ . . _ __ <br />(lnclude al l chanqe orders and adjusl m~nt , *(H'inal Contract amount X-00] ) <br />t.o thp contract_ price) <br />ORIGINAL CONTRACT AMOUNT: INITIAL FEE PAID*: _____ _________- <br />-- _ __ _ <br />+~ (('~~ntract amount X .007) <br />BAI,ANCE DUE : RF.FLIND DUE : <br />_ __ _ . _ <br />(Final contract. fe<- le~s initia] fee paid) <br />Sam~le Calcul.at ion: <br />[~inal Cc7ntracL Amount: $400,000.00 Final I~'ee Due: $400_00 <br />Oriqinal Contrar~t Amt: -~QQ,QQQ~49 lnit ial Fee P3id: ~.~44._SZ4 <br />'I'ot al Ad just ment : $100, 000 .00 Am~~unt I)ue or Refund Duc~ ~ 1100.00 <br />kUocume~ntat ion may consi st~ ot ctlanqc~ orders or <~t her ~•onl ract documt n~-t; Subsl anCiaL iny <br />l tre atn~.>unt c~t l he cont r~act <br />i~/ii/9s ~u~rxi.s~,x (Flease duplicate thln form for future use) <br />