Contracting_Agency_Certification_Form-State.pdf

This is a Contracting Agency Certification Form issued by the Connecticut Department of Labor, Wage and Workplace Standards Division, required under Connecticut General Statutes Section 31-53. The form pertains to an Animal Shelter Renovation and Addition project in Connecticut and must be completed by the contracting agency's authorized representative to certify the total dollar amount of work to be performed. The project encompasses concrete trenching and patching, masonry modifications, interior and exterior removals, plumbing, HVAC, and electrical modifications, along with renovations to restrooms, break rooms, cat isolation rooms, laundry, grooming, and disinfection rooms. The approximately 700 square foot addition features cast-in-place concrete walls and wood joist roof framing built into a slope at the rear of the building, containing storage, dishwashing, and veterinary exam spaces. Exterior work includes concrete sidewalk and chain-link fencing installation, with HVAC design and structural equipment support specifications to be released in a subsequent addendum.

The certification form requires the contracting agency to declare the total project dollar amount regardless of whether the work is executed under a single contract or multiple contracts. The form must be completed with contractor information including the contractor's name, address, authorized representative, approximate starting and completion dates, and submitted to the Connecticut Department of Labor, Wage & Workplace Standards Division, Contract Compliance Unit at 200 Folly Brook Boulevard, Wethersfield, Connecticut 06109. Inquiries regarding form completion or requirements may be directed to the Department of Labor at (860) 263-6790.