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Application for Prevailing Wage Rate Determination

State of Wisconsin

Department of Workforce Development

Issued By the Department Of Workforce Development

Equal Rights Division

Personal information you provide may be used for secondary purposes.

See Section15.04 (1)(m), Wisconsin Statutes for details.

All pages of this form MUST be completed or the application will be returned.

Mail one original copy to Equal Rights Division, P O Box 8928 Madison WI 53708.

Applications may NOT be faxed.

APPLY EARLY! Allow 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) Name of Project

(5) Project Number

[6] Estimated Cost of Completion. Effective July 1, 2001, the TOTAL cost (labor, equipment and material) of

completing a single-trade project must be $35,000 or more, and the TOTAL cost (labor, equipment and material) of a

multiple-trade project must be $172,000 or more. A “single trade project” is defined as one in which a single trade

accounts for 85% or more of the total labor cost of such project. A “multiple-trade project” is defined as one in which

NO single trade accounts for more than 85% of the total labor cost of such project. Indicate the estimated cost for

each of the following:

Site Work

$ __________

General Construction $ ________

HVAC

$ __________

Plumbing

$ __________

Electrical

$ ________

Landscaping

$ __________

Painting & Decorating $ __________

Roofing

$ ________

Concrete

Pavement $ __________

Asphalt Pavement

$ __________

Storm Sewer

$ ________

Sanitary Sewer

$ __________

Water Main

$ __________

Furnishings

$ ________

Miscellaneous

$ __________

TOTAL COST

$ __________

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

County____________________________ City_______________________ Village_______________________

Township___________________

[8] State Agency or Local Governmental Unit Soliciting Bids or Negotiating

For Departmental Use Only

o Section 66.0903, Wisconsin Statutes

Contracts

o Section 103.49, Wisconsin Statutes

[9] Project Will Be

[10] Bid(s) Will Be Taken By

o Bid o Negotiated

o Single Base Bid

o Multiple Base Bids

o Separate Bids

o Other

[11] Advertising Will Begin On

[12] Bid(s) Will Be Opened or Negotiated

[13] Contract(s) Will Be Awarded On

[14] Work Will Start On

[15] Work Will Be Completed On

[16] Will the federal government, or any of its agencies, furnish by loan or grant any part of the funds used for this

project?

oYes

o No

If yes, will the federal government also prescribe a schedule of Prevailing Wage Rates?

o Yes o No

You Must Complete All 3 Pages of This Form

The STATUTORY AUTHORITY for the use of this form is specified in Sections 66.0903 and 103.49, Wisconsin Statutes, and

Chapter DWD 290 of the Wisconsin Administrative Code.

The use of this form is mandatory. Call (608) 266-6860 if you have questions.

ERD-5719 (R. 07/2001)

Form Erd-5719 - Application For Prevailing Wage Rate Determination Issued By The Department Of Workforce Development

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