Application For Prevailing Wage Rate Determination - Department Of Workforce Development - 2010 Page 2
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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
Requestor Signature
Determination Should be Sent
Requestor Title
Organization
Telephone Number
(
)
Requestor Street Address
City
State
Zip Code
18. Name of State or Local Governmental Official or Owner or Developer to Whom the Determination Should be Sent
Title of State or Local Governmental Official, Owner or Developer
Name of State Agency or Local Governmental Unit or Owner or Developer’s “Doing Business
Telephone Number
As” Name
(
)
Address of State or Local Governmental Official’s or Owner or
City
State
Zip Code
Developer’s
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 System
Fire Sprinkler System
Mechanical Insulation
Rough Connection to Municipal System
Refrigeration System
Other (Specify)
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
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