3800-FM-WSFR0471 Rev. 12/2009 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF WATER STANDARDS AND FACILITY REGULATION

    DAVIS BACON WAGE RATE COMPLIANCE FORM

    Recipient Contact Information:

    Recipient Name: PennVest Project Number:

Address: Bid Opening Date:

Contact Person Name:

Telephone: Email:

    Contract Number: Contract Name:

    DOL Rate DOL General Decision Craft Number Rate Fringe

; Provide additional pages as needed to provide all of the anticipated crafts on this contract.

    ; It is acceptable to provide comparable information if it has been prepared previously using a somewhat different

    format.

Send to:

    email: RA-DavisBacon@state.pa.us Questions can be answered by contacting: OR 717-787-0122

    mail to: RA-DavisBacon@state.pa.us Veronica Kasi

    Pennsylvania Department of Environmental Protection Bureau of Water Standards and Facility Regulation Division of Technical and Financial Assistance P.O. Box 8467

    Harrisburg, PA 17105-8467

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3800-FM-WSFR0471 Rev. 12/2009

    INSTRUCTIONS FOR TABLE

Column #1. Craft: Include in this column the job titles for all “laborers” (workers whose duties are manual or physical

    in nature, including apprentices, trainees and helpers) and “mechanics” (workers whose jobs use tools, or jobs that

    perform the work of a trade). Jobs need not be included which are primarily mental, managerial, administrative, executive, professional or clerical.

Column #2. Hourly Rate. Provide the basic rate of pay in dollars and cents.

    Column #3. Hourly Fringe. Provide the total rate in dollars and cents of contributions irrevocably made to a trustee or a third person pursuant to a bona fide fringe benefit fund, plan or program. Benefits may include medical or hospital care pensions on retirement or death, compensation for injuries or illness resulting from occupational activity, or insurance to provide any of the foregoing; unemployment benefits, life insurance, disability insurance, sickness insurance, or accident insurance; vacation or holiday pay; defraying costs of apprenticeship or similar programs; or other bona fide fringe benefits. Fringe benefits do not include benefits required by other Federal, State or local law.

    Column #4. Source of Rate and Fringe. Provide the source of information you used to determine your hourly rate and fringe rate. In most cases it is expected that the source for this information will be from the U.S. Department of Labor Web site (http://www.wdol.gov/dba.aspx#0). Document the specific source from the Web site with the General

    Decision Number as in the following example: DOL GDN: PA080001 07-24-2009 PA 1.

    If the particular craft is not listed in the DOL Web page for the principal county where the work will take place, it is the responsibility of the sub-recipient to recommend an appropriate rate and fringe based on other documentation. One alternative source is the state wage rate/fringe for the craft (see

    http://www.dli.state.pa.us/landi/li_apps/pw_menu.asp?landiPNavCtr=l&TNID+3451#3451). If a state wage and fringe

    is not available then the sub-recipient is required to recommend appropriate figures and briefly explain the basis for this recommendation.

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