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APPLICATION FOR PREVAILING WAGE RATE DETERMINATION

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APPLICATION FOR PREVAILING WAGE RATE DETERMINATION Powered By Docstoc
					 State of Wisconsin
 Department of Workforce Development                Application for Prevailing Wage Rate Determination
 Equal Rights Division                            Issued By the Department Of Workforce Development




                                                                                                                                  FOR DWD USE ONLY
 Personal information you provide may be used for secondary purposes. Privacy Law Section 15.04 (1)(m),
 Wisconsin Statutes.

 The STATUTORY AUTHORITY for the use of this form is specified in Sections 66.0903, 66.0904 and 103.49,
 Wisconsin Statutes, and Chapter DWD 290 of the Wisconsin Administrative Code.
 The use of this form is mandatory. All three pages must be completed. If you have questions, call (608)
 266-6860.
 Either mail or fax your completed form, but do not do both. Mail one original copy to Equal Rights Division,
 PO BOX 8928 MADISON WI 53708 or fax to (608)267-0310.

 APPLY EARLY! ALLOW AT LEAST 30 DAYS to have your application processed.
 1. Date of Request           2. Desired Date of Receipt      3. Prior Determination Number Issued For This Project

 4. Project Name                                                                    5. Project Number



6. Estimated Cost of Completion. Effective January 1, 2010, the TOTAL cost (labor, equipment and material)
   of completing a project of public works under Secs. 66.0903 or 103.49, Wis. Stats., must be $25,000 or
   more. Effective January 1, 2010, the TOTAL cost (labor, equipment and material) of completing a publicly
   funded private construction project (i.e., a project in which the developer, investor, or owner of the
   project receives direct financial assistance from a local governmental unit) under Sec. 66.0904, Wis. Stats.,
   must be $1,000,000 or more. Indicate the estimated cost for each of the following:
      Site Work                    Water Main                        Storm Sewer                    Concrete Pavement

      Plumbing                     General Construction              Furnishings                    Sanitary Sewer

      Painting & Decorating        Electrical                        HVAC                           Miscellaneous

      Asphalt Pavement             Roofing                           Landscaping                    TOTAL COST


 7. Indicate EXACT Location of Project (Specify the County and then ONLY the City, Village or Township):
        County Of                       City Of                        Village Of                       Township Of

 8.     Name of State Agency or Local Government Unit which is soliciting bids or                  For Department Use Only
        negotiating contracts for the project of public works OR                                    Section 66.0903, Wis. Stats.

        Name of Owner or Developer who is soliciting bids or negotiating contracts for a            Section 103.49, Wis. Stats.
        publicly funded private construction project
                                                                                                    Section 66.0904, Wis. Stats.
 9. Project Will Be                    10. Bid(s) Will Be Taken By
       Bid          Negotiated                Single Base Bid          Multiple Base Bids         Separate Bids
                                              Other (Specify)
11. Advertising Will Begin On                                        12. Bid(s) Will Be Opened/Negotiated On

13. Contract(s) Will Be Awarded On                   14. Work Will Start On                 15. Work Will Be Completed On




 ERD-5719-E (R. 12/2009)
                                                                2
16. Will the federal government, or any of its agencies, furnish by loan or grant any part of the funds used for this project?
        Yes            No
    If yes, will the federal government also prescribe a schedule of Prevailing Wage Rates?
        Yes            No
 17. Requestor Name to Whom a Copy of the Determination Requestor Signature
     Should be Sent

     Requestor Title                                                Organization                          Telephone Number

     Requestor Street Address                                                 City                        State       Zip Code

 18 State or Local Governmental Official or Owner or Developer Name to Whom the Determination Should be Sent

     State or Local Governmental Official, Owner or Developer Title


     State Agency or Local Governmental Unit Owner or Developer Name                                      Telephone Number

     State or Local Governmental Official Owner Or Developer Street           City                            State    Zip Code
     Address

 19. In the space below give a brief written description of the work to be performed on this project




 20. For projects involving a new building or addition to an existing building indicate the number of levels or stories
         1                   2                3                4-9              10 or more
      Scope:
         New                 Addition         Alteration       Renovation       Remodel        Repair            Demolition
 21. Indicate size only if a new building or addition to an existing building
     Square Feet                                                   or Cubic Feet
 22. CONCRETE
       Poured Floor, Driveway, Yard, Road, Street                    Other Poured (Plain or Reinforced)
       Precast (Reinforced or Prestressed)
        Other (Specify)
 23. MASONRY
        Brick                                   Exterior Insulation Finish System                          Ceramic Tile
        Marble                                  Masonry Caulking                                           Plaster
        Tuckpointing                            Stone                                                      Block
        Terrazzo
        Other (Specify)
 24. HEATING AND VENTILATION
        Hot Water                               Infrared                                                   Solar
        Steam                                   Electric                                                   Warm Air
        Air Conditioning
        Other (Specify)
 25. PIPING
        Finish Plumbing                       Process Piping                                        Steamfitting
        Gas Piping                            Rough Connection to Septic or Disposal                Fire Sprinkler System
        Mechanical Insulation                 System
        Refrigeration System                  Rough Connection to Municipal System

        Other (Specify)
                                                           3
 26. ELECTRICAL
       High Voltage                                Traffic Signal                                Cable Plowing
       Low Voltage                                 Street Lighting                               Voice or Video
       Cabling (Encased)                           Outdoor Lighting                              Telephone
       Fire Alarm                                  Computer Wiring
       Other (Specify)
    Service will be fed and controlled by(Check one):
       Overhead Wires or Cables                                 Underground Wire or Cable
27. PAINTING AND DECORATING
       Brush                                       Sandblasting                                   Spray
       Pavement Marking                            Drywall Taping                                 Roller
       Wallpaper                                   Swing Stage Work
       Exterior Insulation Finish System           Lead Abatement
       Other (Specify)
28. METALS
       Reinforcing, Structural, or Ornamental Ironwork                                            Lashing
       Sheet Metal
       Other (Specify)
29. ROOFING
       Asphalt Shingle                            Standing Seam Metal                             Slate or Tile
       Built-Up                                   Urethane Foam                                   Wood Shingle
       Precast Slab                               Elastomeric or Elastoplastic
       Other (Specify)
30. EXCAVATION AND OTHER SIMILAR WORK
       Building Excavation                        Compressed Air Tunnel                           Caisson
       Hydraulic or Mech. Dredging                Bulk Excavation                                 Demolition
       Well Drilling                              Pipe, Sheet or “H” Piling                       Rough Grading
       Storm Sewer                                Footing or Foundation                           Free Air Tunnel
       Sanitary Sewer or Water Main               Trenching (# Lineal Ft. and Max.Depth)          Railroad
       Marine Construction on Great Lakes         Clearing or Grubbing Land
       Other (Specify)
31. SURFACING AND PAVEMENT
       Mineral Aggregate                          Bituminous                          Concrete
   Number of Lineal Feet or                  Number of Square Feet or            Number of Cubic Feet

32. LANDSCAPING
      Seeding                                   Planting Trees, Shrubs,              Sodding
      Lawn Sprinkler                             Bushes, etc
      Other (Specify)
33. OTHER WORK
      Carpenter                          Installation of Heavy Machinery or equipment             Glazing
      Cabinetry                          Asbestos Removal or Abatement                            Siding
      Acoustical Ceiling Tile            Dampproofing or Waterproofing                            Trucking
      Lathing                            Carpeting or Soft Tile                                   Drywall Hanging
      Elevator or Escalator              Temperature Control
      Underwater Diving                  Flagging or Traffic Control
      Overhead Door Installation         Batt or Blown Insulation
      Fence or Guard Rail                Hazardous Material Removal (Except Asbestos)
      Other (Specify)

				
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