Form Erd-5719 - Application For Prevailing Wage Rate Determination Issued By The Department Of Workforce Development Page 2
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[17] Name of Requestor to Whom a Copy of the Determination Should be Sent
Signature of Requestor
Title of Requestor
Organization
Telephone Number
(
)
Street Address of Requestor
City
State
Zip Code
[18] Name of State or Local Governmental Official to Whom the Determination
Title of State or Local
Should be Sent
Governmental Official
Name of State Agency or Local Governmental Unit
Telephone Number
(
)
Street Address of State Agency or Local Governmental Unit
City
State
Zip Code
[19] In the space below PRINT or TYPE 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
o1
o 2
o 3
o 4-9
o 10 or more
Scope:
o New
o Addition
o Alteration
o Renovation o Remodel
o Repair o Demolition
[21] Indicate size only if a new building or addition to an existing building:
Square Feet _______
or Cubic Feet _______
[22] CONCRETE
o Poured Floor, Driveway, Yard, Road, Street
o Other Poured (Plain or Reinforced)
o Precast (Reinforced or Prestressed)
o Other (Specify) __________________
[23] MASONRY
o Brick
o Exterior Insulation Finish System o Ceramic Tile
o Marble
o Masonry Caulking
o Plaster
o Tuckpointing
o Stone
o Block
o Terrazzo
o Other (Specify) _______________
[24] HEATING AND VENTILATION
o Hot Water
o Infrared
o Solar
o Steam
o Electric
o Warm Air
o Air Conditioning
o Other (Specify) _______________
[25] PIPING
o Finish Plumbing
o Refrigeration System
o Steamfitting
o Other (Specify) ______________ o Process Piping
o Fire Sprinkler System
o Gas Piping
o Rough Connection to Septic or Disposal System
o Mechanical Insulation
o Rough Connection to Municipal System
(26) ELECTRICAL
o High Voltage
o Traffic Signal
o Cable Plowing
o Low Voltage
o Street Lighting
o Voice or Video
o Cabling (Encased)
o Outdoor Lighting
o Telephone
o Fire Alarm
o Computer Wiring
o Other (Specify) _________________
Service will be fed and controlled by(Check one):
o Overhead Wires or Cables
o Underground Wire or Cable
[27] PAINTING AND DECORATING
o Brush
o Sandblasting
o Lead Abatement
o Pavement Marking
o Drywall Taping
o Spray
o Wallpaper
o Swing Stage Work
o Exterior Insulation Finish System
o Roller
o Other (Specify) _______________
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