Okaloosa County BOCC — May 15, 2013 — CW Roberts Certified Payroll — reading text

OF THE UNITED STATES CODE, U.S, Department of Labor PAYROLL =WH Wage and Hour ivislan (For Contractor's Optional Uses See Instructions at www.dol.goviwhdlforms/wh347instr. htm) US, Wage and Hour Dison Persons arg notraquled ta respond to the collection of information unless it csplaya a curently Valid OMB contol uber Rev, Deo, 2008 NAVIEGFGONTRAGTOR [J OR GUBCONTRAGTOR [7] ADDRESS 4995 Hidden Terrace Drive ONIB No.: 1235-0008 Bill Smith Elactio, Ina, Cantonment, FL 92538 Explees! 01/94/2015 PAYROLL NO. FOR WEEN ENDING PROJECT AND LOCATION PROIEET OR CONTRACTWO, a o1ig/2018 NWF Regional Alport Rehab Publte Parking 19884 Faclitfes, Okaloosa County C12-1888-AP w @ ro) (0 DAY AND DATE o| ® T 7 cy 4 : DepUChons 6: id ATH WAGES eewarramaaeorccom ean” (8B) vow (elo L ale [ofi[2 [Blom] gare | a wie] &@ |, | ae NUMBER) OF WORKER E CLASBIFICATION HOURS WORKED EACH OAV HOURS|__OF BAY EARNED FIGA, TAX, OTHER _|DEDUCTIONS| FOR WEEK Roderick Wolfe 6906 Electiiclan fo se 00] $2538 [8594 0 357.98 | $103.00 sioss |’ $596.96 es ee 24,0() 1205 Soon94 Josh Webb 4476 General fo 5240.00 2 Laborer $an31 | $16.00 $8815 $145.48 | $394.54 3 saa am 16.04 1500 <séo.00 Travis Tucker 4377 Electrician =o $306.90 1 $35.65 | $44.00 | $36.83 $1648 | $386.42 sf am] [soo ean 18,0¢} 1208 ‘50290 ° 3 ° 2 ° ° ° 5 a A SOFA 688, Bah The Copdlend At ‘While completion of Ferm W4H.347 [seplional, lls mandatory for anvared contraniars and aubsorivactors performing work on Faciraly fnanced ce aesleted aonstrution coriract 1 taspond tothe nfrmetion coltecion cantalned in 2 dd 0.8.0, § 3446} contactors and aubcentrecios perfimiing wack on Federally hanced or azaleted conslrveton contracts fo urrish wacky astafernant wilh reapac othe vages peld each employes ering the preceding week.” L1.S, Department of Laber (DOL) raguations at 29G.FR. §:5(6)(2}) requir contesctors fo eubrail weekly a copy of al payrale (athe Federal apancy contracting for ar dancing the construction project, eccampaniod by n signe "stalement of Complance® Indcatng thal the payrolls ara correct and complete er that each laborer ‘or mothanle haa been pald notless than Ine propar Davit-Bacen prevaling wage rate for the work performed. DOL and federal canracting agnciaa reveling the Inormallon revi the Information fo determine that employes have received iegelly raquleed wagos and tings ene, Publfa Burden Stalement ‘Wa estate that Is wil fake an average of 6S minutes to complete ths collin, Inaléfng te for ravlewing Inetrucfons, searching existing data sources, gatharing and malhilring tha data ngadd, and completing ond roving the calention of Information. you hava lesa eatimatss or any ahar aspect of thls calcton, nein suggeations for reduning thi burden, send then othe Adminstrator, Wage and Hour Dial, LS, Deperiment of Leber, Reom 83502, 200 Consifuton Avenue, NW. any commons regar ‘Washington, D.C. 20210 cr) Date __ 01/44/2013 Sarah Harper Payroll Clerk (Name of Signatary Party) (Title) do hereby state: (1) That pay or supervise the payment of the persons employed by Bill Smith Electrio, inc, onthe ‘(Contractor of SUbéartractor} NWERA Parking Rehab } that during the payroll perlod commencing on tha ‘Building ar Wark} St dayet_ 12, 2012 | endencing the 8 aay ot__41__,_2013 | alt persons employed on a ald project have been pald the full weekly wages eared, that no rebates have besn or will ba made aither directly or Indirectly to or on behalf of sale Bill Smith Electric, Inc. ‘Goniractor or Siibeantracior) trom the full weekly wages earned by any person and that no deduc flons have been m ade elther diraatly or Indirec thy {tom the full wages earned by any person, cthar than parmisslbfe deductions as defined in Regulations, Part 2,29 CFR, Subite A), Issued by the Seartery of Labor under ibe Copsland Act, as amended (48 Stat, $48, 89 Start, 108, 72 Stat, 967; 76 Stat, 387; 40 U.S.C, § 3148), and described below. FICA, Federal Withholding, Medical tasurance (2) That any payralis otherwise under thls contract required { 0 be s ubmitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are nt less than the applicable wage rates contained in any wage det armination Incorporated Int ot he contract; t hat t he classifications set forth therein for each fabarar ar mechanle conform with the work he performed, (@)T het any apprent ices em ployed Int he sbov eperiod are duly registered in a bona fide apprenticeship program regia tered w Ith a St ats apprent loeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, of ifno such recognized agency exists Ina Sate, aro reglatered with the Bureau of Apprenticeship and Trafning, United States Department of Labor, (4) That: (@) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS Cn xtton to the basis hury wage rats paid fa each labret oF mechani tte in the above referenced payroll, payments of fringe benefits a8 fisted in the contract have been or willbe made to appropria fe progra ms for the bene fit of such employees, excapt as noted in section 4(c} below, {o) WHERE FRINGE BENEFITS ARE PAID IN GASH [ZI — ‘E2ch iaborer or machanls listed In the above referenced payroll has been ald, as Indicated on the payroll, an amount not less than the aum of the epplicable basic hourly wage rate plus the amount of the requirad fringe benefits as listed in the contract, except ag noted in saotlon 4(c) belaw, (©) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS: NAME AND TELE ‘Sarah Harper, Payroll Clerk TE WHF FALSPEATIONS FANS FT TE AIO STATEMENTS MT AV SUB] EOTT HeGO MIRACTORO R BUBOONTRAGTOR TO GIVIL OR CRIMINAL PROSECUTION, SEE SECTION 1001 OF TITLE 18 AND SECTION 251 OF TITLE 34 OF THE UNITED STATES COD, U,S. Department of Labor PAYROLL ‘Wage and Hour Divtelon (For Contractor's Optional Use; See Instructlons at waw.dol.gov/whdiformalwh347instr.him) U.S. Wage and Hour Division Rev. Dec, 2008 Persons ate not required te raspend fo the coltection of information untese It displays a currently valid OMB contro! number. NaMBOF CONTRACTOR [] OR EVACONTRAGTOR ADDRESS 1995 Hidden Terrace Drive ‘OMB No.: 4286-0008 Bill Smith Eleclrle, Ino. Cantonment, FL 32693 Expires: 01/31/2018 PAYROLL NO, FOR WEEKENDING PROJEGT /ND LOCATION PROWEDT OR CONTRAGT NO, 40 01/06/2013 NWF Regional Altport Rehab Public Parking 19394 Faclities, Okaloosa County C12-1838-AP % a @ TibAY AND DATE co) e w a ro) . DEDUCTIONS NAME AND INDIVIDUAL IDENTIFYING NUMBER, H eat mal iss her (e.g, LAST FOUR O1GFTS OF sooIA seouRTY [8 4 WoRK ett dzfafs[s [6 bora) pare Gass. woe | wee | RR, you. | “Se AUMBER OF WORKER, g CLASSIFICATION HOURS WORKEREACH GAY “HoURs|_ormay | eamved | rica | tax | ome _jneoUcTIons| FoR WEEK Roderlck Wolfa 6908 Electrician fo 5221.65 Q $28.66 | $42.00 s7o.6s | $303.99 afasof [0 13,0q 70s ‘oss Henty Black 1416 Blectriolan — o [s50.15 1 $40.01 | $58.00 | $46.57 $144.58 5425.07 3 1795 “ 300 $562.65 Travie Tucker 4377 Electrician fo SIS 1 $24.12 | $22.00 | $36.83 $2.93 | 8269.20 8 a0 1n0s 3.00) We $352.15 0 6 ° 3 ° fo e ° 8 lation of Form WH-S47 ls optiona, lls mandatory for eovered eanirgolars and eulscantaetere parforming work on Fara Anencod! or agslated conalucion coniracts to reapand ta he Information celleclon contained ir 28 CFR. §§ 3.5, 5.8) The Copeland hat 2148} contractors and subcontractors perfonaing work on Paderally Snanced or aslsted contruction conitacts fo urnish wacky a statement with raspect fo the wages pald euch employee during the preceding wal,” U.S, Department of Lebar (BOL) regulations a1 20G.F.R. 8 6.6()(3)0 requre contractors te aut week a copy of el payrlls to the Fadevel agency corkracting for ox fnanding the constuction project, accompanied by a eed “Statement of Gompllanco”Ineftatng that fa neycoa ere correct en complete and thal eaah bare Cormaehanis has been pald notless then the propar Davie-Bacan pravaling age rat forthe Work performed. COL and federal confracng agenclea receiving ths infazmalionreviaw the Information to determin that emplayses have raceWved lagay required wages an hinge banat. ‘ite com Us, Pubite Burien Btatement {We eutiiate tha Js wl take an average of 86 minutes fo campleta this allecton, inlualngthne fr revfewing Instruations, searching exsting data sovress, gathering snd aeinilring ths data needod, and comptefing and reviewing the aollacan of fermen. W you Rave ‘any comments regatalng theea eellmates or eny other aspact ofthis ellecton, Inlucng euggestions for fedvelng As burden, send them tothe Administer, Wage and Hour Divsfan, U.8, Department of Labor, Reem 83502, 200 Censiuton Avante, NW, ‘Wesningion, D.C. 20210 rw) STATE OF FLORIDA DEPARTHIENT OF TRANSPORTATION Se erebery Statement: ne DATE iN as L Debra Whi ae WAGE AND HOUR RECORD (c) EXCEPT [KCEPTICN (CRAFT EXPLANATION Joveto-ss ‘Conavtion (Name of signatory pariy) Citey do hereby state! (1) That I pay or supervise the payment of the persons employed by Bersorel Moma Bunldape Uy on the Hot Roniond AS epoet ” (Contractor or Subcontractor) a) 3 (Bullding of world) that during the payroll perlod commencing on the¥ _day of rnd andanding the <Q G dayof = Alghombinn parsons employed ‘on sald project have bean pald the full weekly wages eamed, that na rebates have been or wll asad made they dg iy or Inger fpgron ron Debate Orn Me from the full weekly (Contractor or ders \wagas earned by any person and that no deductions hava ben made efther directly or Indirectly fram the full wages aarned by any parson, olher then permissible deductions as defined in Regulations, Part 3 (29 CFR Sublitle A), Issued by the Seoretary of Labor under the Copeland Act, as amended (48 Stal. 948, 63 Stat. 108, 72 Stat. 987; 76 Stal, 987; 40 U.S.C, 3148), and dasoribad below: [ I t REMARKS: ew “Ent SMES BAS Set Attach p nN erasal 2]. That any payrolls olhenwvise under this contract required (o be subsites for the above period are cotract and complete; that the wage rates for laborers oF mechanics cantalnad therein are not fess than the applicable wage tates contained in any Wage Geterminalion incorporatad into the contract; that the cfaselfeations set forth therein for each laborer or mechanic conform with tha work ha performed. {3}, That any specenices employed in tha shove pared ara duly raglstared in & bona fda iceenip ageney recaghizéo ny ta bureau er Apprenticeship tnd Taning Uned Sten Depertnent ef boro lino such recagelzed egancy ex ina Slate, are registered wi tha Bureau of Apprenilceship and Training, United States Dapariment of Labor. (4) That: fa) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR PROGRAMS In adaiion to the baslo hourly Wage rates paid to each laborer or mechanie lleted in tha above referenced payroll, payments of Hinge benefits as lsted Inthe ‘aontract have bean or wil be mada to approprials programs for th benefit of such employees, excapt as nofed in Sedlion 4{c} below, (b) WHERE FRINGE SENEFITS ARE PAID IN CASH Each faborer or mechanic isted in the above referenced payroll hae been paid, as Indicated on the payroll, an amount not less than the surn of the appticabts beste hourly wage rate plus the amount of the required (tinge ‘benefits as listed In the contract, excapt as noted in Section 4(o) below: NAME AND THLE [SIGNATURE Beeston | sla La THE WILLFULFALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TOCIML OR CRIMINAL PROSECUTION, SEE SECTION 1001 OF TITLE 18 AND SECTION l231 OF TITLE 31 OF THE UNITED STATES CODE yo0.ataca weene7 Conenueten ee Wage and Hour Record: Contactors Name C Personal Home Bulidars, no. ] Adtrase [eas rece Soa oss Weuwis, Fog SHI6t ] Payrott Numbert CYS) rerweoceni § COTES cont pee Pctand Locator, (Sv agial supa Wonton te. spake ine (4) Day and Date | Sh, [oaffaa] pebec 0) Detluctions wet lagen | Tot rom oT te oa Se aca TS Sata] paat | ease | Tote com fedigl Spend