Small Works Roster Application

Primary Contact Name
Business Address(Required)
Mailing Address(Required)
Persons authorized to sign bids, proposals and contracts(Required)
L&I Registration Expiration Date(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.
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.
Contractor Type(Required)
Qualified Disadvantaged Business?(Required)
Is your Business Registered as a Qualified Disadvantaged Business Enterprise (small, minority and/or women owned business)?
Identify three (3) clients who will serve as references:
Client 1(Required)
Name
Phone
Email
Client 2(Required)
Name
Phone
Email
Client 3(Required)
Name
Phone
Email
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.
Clear Signature
Date(Required)