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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. 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

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

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 Of

City Of

Village Of

Township Of

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

Section 103.49, Wis. Stats.

for a 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

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

ERD-5719 (R. 12/2009)

Application For Prevailing Wage Rate Determination - Department Of Workforce Development - 2010

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