Small Works Roster Application

Name of Business(Required)

Phone(Required)

Email(Required)

Website

Labor & Industries Contractor Registration Number(Required)

Unified Business Identifier (UBI)(Required)

W-9 Form(Required)

If you don't have a W-9 Form available, you can download a blank form here: W-9 Form

Accepted file types: jpg, gif, png, pdf, heic, Max. file size: 128 MB.

How many years has this business been in operation?(Required)

What is the name of your insurance company?(Required)

Proof of Insurance

Current insurance certificate naming "Public Utility District No. 1 of Jefferson County" as additionally insured.

Accepted file types: jpg, gif, png, pdf, heic, Max. file size: 15 MB.

Other Service(s) Provided:

What is the maximum dollar value of work that your firm is capable of undertaking?(Required)

Identify three (3) clients who will serve as references:

The applicant is hereby notified that all Washington State laws regarding prevailing wages and non-discrimination are applicable to ALL small works roster contract activities.

All work is subject to Washington State Prevailing Wage.

I CERTIFY THAT INFORMATION SUPPLIED HEREIN (INCLUDING ALL PAGES ATTACHED) IS CORRECT.

Signature(Required)

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