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APPLICATION FOR PREVAILING WAGE RATE DETERMINATION

ISSUED BY THE DEPARTMENT OF WORKFORCE DEVEL0PMENT

Equal Rights Division – Labor Standards Bureau

INSTRUCTIONS: Both sides 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. Hand-delivered applications should be directed to the division at 1 South Pinckney,

Room 320, Madison, WI. APPLY EARLY! Allow 30 days to have your application processed. The STATUTORY AUTHORITY for the use of this form

is specified in ss. 66.293 and 103.49, Stats., and Ch. DWD 290 of the Wis. Adm. Code. THE USE OF THIS FORM IS MANDATORY. Call (608) 266-

3193 if you have questions.

Personally identifiable information you provide may be used for secondary purposes. See Section15.04 (1)(m), Wis. Stats. for details.

[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 January 1, 2000, the TOTAL cost (labor, equipment and material) of completing a single-trade project must

be $34,000 or more, and the TOTAL cost (labor, equipment and material) of a multiple-trade project must be $168,000 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

$ ________

HAVC

$ ________

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 Contracts:

For Departmental Use Only

o Section 66.293, Wis. Stats.

o Section 103.49, Wis. Stats.

o Single Base Bid

o Multiple Base Bids

o Separate Bids

o Other

[9] Project Will Be:

[10] Bid(s) Will Be Taken By:

o Bid o Negotiated

[11] Advertising Will Begin On:

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

[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? o Yes

o No

yes, will the federal government also prescribe a schedule of prevailing wage rates? o Yes o No

[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 Should be Sent

Title of State or Local 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

FOR DWD USE ONLY

YOU MUST COMPLETE THE BACK OF THIS FORM

ERD-5719 (R. 12/2000)

Form Erd-5719 - Application For Prevailing Wage Rate Determination Issued By The Department Of Workforce Devel0pment

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