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

OFFICER do ly sate SEO MEY panes ne eM aE ac ene eg ty cw, Robe ontenng, te ote (buttding or work) NWFRA Rehab of Pulble Parkin, that during the payrol perod 1/24/12 ~~ 12012 cat parsons employed on ga ee ee begat me, es er A antes Te Clee, Tem FLAC - Dental 7 Advance: AFLAC = Hosp. . (PLAC STE *__APLAT Em E-CWR __Mith-F-CWR Am-EC- CWR __Hth- ES - OWR, SOTK_ WR Loan #7 Mss, (2) That any payrolls thenwiss under thls conlact_ required to be submitled for the above period aro correct and complete: Thal the waga rales for laborers ard mechanics contained therin ara not less than the applicabla wage rales contained “In any wage delermination Incorporated Into the contract; that the classificaon set forth for each taborer or mechanic conform with the work performed (®) That any apprentices employed In tha above period are duly registered In @_bons fide apprenticeship program! registered with a Slate apprenticaship agency recognized by the Bureau of Appreniiceship and Training, Uniled States Department of Labor, or if ng such recognized agency exists in a Stale, ara registered . with the Bureau of Apprenticeship and Trang, United States Department at Labor (4) That: (2) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS In addition {9 the basic ‘hourly wags rates paid to each laborer or mechanic listed In tha above referenced payroll, payments of fringe benefls as listed In the contrac have been cr will ba mada to appropiate programs for the benef of such smployoss, sxcspt as noled in Secllon 4 (¢} below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH Each laborer or mechanic istad im tha above referenced payroll fas pald, a8 Indicated on the payroll. an amout rot (ess than the sum of {he applicable basic hourly rate plus the ameut of the required frlogs tenets as sted In tha contact, except as noisd in Sectlon 4 (¢} below. (6) EXCEPTIONS (CRAFT) EXCEPTION EXPLANATION No WORK WEEK Remarks NAME AND TITLE SIGNATURE SHARON MACKEY EEO _OFFICER LA tons THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE conphacror of fusconrmaeron TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 291 OF TITLE 31 OF THE UNITED STATES CODE 56272 C.M, Robarte Contracting, Tac. 337% capital cixcle NE Tallahaeuerc 22208 Soo.Sec,flo FNS Dep # CAL Mm Craft step Heme/addreae rk Date - 14 = cheok Detail. . Page C. #. Robart Construction Date + 1foa/1s Gextitied Payroll Report u/eringe Info Pertod mad - 12/30/12 Period Na. = 05 gob Ho. apiioay NWFRA Rehab of Public Parking Okalecea Co. Boce - «Regular. = overtime . . Other —Totat ab Hous Rate Moura = Rata rs, ours © amount NO WORK PERPORNED ~ Description amount Fringe Benefits: Data 1219/2012 j Sarah Harper Payroll Clerk {Name of Signatory Party) (Title) do hereby state: (1) That | pay or supervise the payment of the persons employed by Bill Smith Electric, Ine, onthe (Contractor of Subcontractor) NWFRA Parking Rehab ; that during the payrolt period commencing on the Gillding or Work) 19 tayof a 2012 and ending the_25 _ day ot it 2012 all porsons amployed on s ald projact have been paid t he full weekly wages eemed, that no rebates have been or will be made either directly or indirectly to or on behalf of said Bill Smith Electric, Inc. (Contractor ar Subcontractor) weekly wages earned by any person and t hat no deduc tlons have bean m ade either directty or indies ty from the {ull wages aamed by any person, other than permisalble deductions as defined In Regulations, Pert ‘Subtitle A), lesued by the Secretary of Labor under the Copeland Act, as amended (48 Stat, 948, 8, 72 Stat. 867; 76 Stat. 367; 40 U.S.C. § 3148), and describad below: from the full a (29. 63 Start, FICA, Federal Withholding, Medical Insurance (2) That any peyrolls otherwise under this contract required f 0 be s ubmitted for the above period ara correct and completa; that the wage rates for laborars or mechanics contained therein are not less than the applicable wage rates contalned In any wage determination incerporated Int ot he c onlract; t hat tha classifications set forth therein for each laborer or mechanic conform with the work he parfarmed. (2)T hat any epprent Ices em ployed Int he abov @perlod ara duly reglstered in a bona fide apprenticeship program regis tered w Ith a St ate apprent tcaship agency recognized by the Bureau of Apprenticeship and Tralning, United States Department of Labor, or ifno such racognized agency exists in a Slate, ara registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (®) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS OF ~ in sastton tothe baste hourly wage retespald to each aberer or mechanic Hated in the above referencad payroll, payments of finge bene ts as listed In the contract have been or willbe made to apprapria te progra ms for the bene ft of euch employees, excent as noted in section 4{c) below, (b) WHERE FRINGE BENEFITS ARE PAID IN CASH [ZI — Each laborer or mechanic iisted in the above referencad payroll has been pald, ae Indteated on the payroll, an amount not lass than the sum of the applicable basle hourly wage rate plus the amount of the required fringe beneffls as llated In fhe contract, excapt as noted In section 4(o) below. (¢) EXCEPTIONS EXGEPTION (CRAFT) EXPLANATION REMARKS: NAME AND TITLE ‘Sarah Harper, Payroll Clark PRC hop -toups THE WILLFUL FALEIFIGATIONO FANYO F FRE AGO VEST ATEMENTSM AY SUBJ ECT T HECO NTRAGTORO R. SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION, SEE SECTION 1001 OF TITLE 18 AND GECTION 291 OF TITLE 31 OF THE UNITED STATES CODE, U.S, Department of Labor PAYROLL SH Wage and Hour Division (For Contractor's Optional Use; See Instructions at www.dol.goviwhd/farma/wh347Inetr. htm) USS, Wage and Hour Division Persons are not requited ta respond to the colfection of Information untees it displays a curranily valid OMB controf number, Rey, Dec, 2008 NAME OF CONTRACTOR [_] OR SUBCONTRACTOR [g] [ADDRESS 4095 Hidden Terrace Drive OMB No.: 1235-0008 Bill Smith Elactric, Inc. Cantonment, FL 32533 Expites: 01/34/2016 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR GONTRAGT NO. 34 stter2012 NWF Regional Alport Rehab Publle Parking ©12-1990-AP | Facilities, Okaloosa County ‘ 1) (2) 3) (4) DAY AND DATE (6) (8) al @ [oT FF 8] m] [wre] F] 8] 8 DEDUCTIONS ex NAMIE AND INDIVIDUAL IDENTIFYING NUMBER — |, 8 r aces (bar LAST FOUR 017s GF SOCIAL SECURITY a work [19 [20 [oi [20 [25 [24] 25 ora are | at wocowe | Mem | cHD roma, | “pam NUMBER) OF WORKER, z CLASSIFICATION, tOURS WORKEO EACH DA) {OURS} OF PAY. EARNED. FICA. TAX “ OTHER |DEDUCTIONS| FOR WEEK Trevis Tucker 437 Electrician — fo 842.63 1 $14.96 | $15.00 | $36.83 $66.79 $234.84 3 a0 2,30) in0s Sous Henry Black 1416 Electticlan = fo $42.63 1 $17.54 | $26.00 | $46.57 $90.11 $267.02 8 ’ 05 “ 2.50 $357.13 Tim Rutherford 5113 General ° $25.00 2 Laborer C $13.56 | $5.00 gig.sé | $221.44 ° F 0 x 2.50} toa $240.00 sista canetruction contracts to respond (0 the Infmetian calleclon contalned In 29 C.F.R. §$ 3.3, 5a). The Copeland Act a with reepactio the wages paid ach employee during ino preceding Week." U.S, Depsrtmenit of Labor (DOL) regulaions at Tex or financing the project, docompanlad by a signed "Statement af Complianca"Indlzating thatthe payrolls ara cotract and eamplate and thet each laborer 1 adonales receiving tis raview the fe determine that have recslvad lagaly zoqutsd wages end tings benofle, While completion of Form WH-347 Is options lla msndataty for ervarad! conractora and subcontractors perfoiming work an Federal tnencad or (40 U.8.. § 3148) contractors and suticontraciars performing week on Federally finaraed ore ied aerctan cara “nh weak 2 8(a}(2KI) raqulre contractors to submit weekly copy of ell payalls to the Federal ar mechani hee baen paid al lees han fa proper Ravie-ecor provallog wage ae fr ho work perfomes, DOL ae eda Public Burden Statement ‘Wa estimate that Is wil lake an average af 86 minutes fo complete this collation, Including tine for reviewlng Insructons, sesrching evicting data sources, gathering and malnisning the data neadad, and completing and ravlewing the collection of Information, Ht you hava any comments tagarditg thoes estimates or any alher a¢pect of this callention, Ineluding euggestions for reducing this burden, send tham to the Adminisraior, Wage and Hour Divison, U8, Dopartmarl ef Labar, Room $8602, 200 Conatlutlon Avenue, N., Washington, 0.C, 20240 roy taistiaote {b) WHERE FRINGE BENEFITS ARE PAID IN CASH Date Sarah Harper Payroll Clerk 4 ui = Each fsborer or mechanic liste in the above referenced payroll has baen paid, (Name of Signatory Party) (Title) as indicated on the payroll, an amount not lags than the sum of the applicable do hereby state: basic hourly wage rate plus tha amount of the required fringe benefits aa listed In the contract, except as noted In section 4(c) below. (1) That ! pay or suparvise the payment of the persone employad by (e) EXCEPTIONS Bill Smith Electric, Ino. onthe ‘Contractor or Subcontractor) EXCEPTION (CRAFT) EXPLANATION NWFRA Parking Rehab ; that during the payroll period commencing on the ‘Building or Work) a1 ceyot_ 122012 | and encing tha_23 _ day of all persons employed on s ald project have bean pal t he full weakly wagea eamed, that no rebates have been of willbe made alther directly or indirectly to at on behalf of said Bill Smith Electric, Inc. from the fa (Contractor or Subcontractor) weekly wages aamed by any person and t hat no deduc tions have been m ade elther dlractly or indires ty. from the full wages earned by any person, ather than permissible deductions ae defined In Raguistions, Part 3 (29 G.F.R, Subtille A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat, 948, 63 Start. 108, 72 Stet, 967; 76 Stat, 367; 40 U.S.C, § 3146), and described below, FICA, Federe! Withholding, Medical insurance 12 2042 "REMARKS: {2) That any payrolla otherwise under this contract required t o be s ubmitted for the above period are coect and complete; that the wage rates for laborers or mechantcs oontalned therein are not Jase than the applicable wage rates contained In any wage det ermination incorporated Int ot he c ontract; t hat t he classifications set forth thereln for each laborer or mechanic conform with the wark he performed, (3) T bat any apprent ices em ployed Int heabov a period are duly registered In @ bona fide apprenticeship program regis tered w ith a St ate apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or [Fo euch recognized agency existe in a ‘State, sre registered with the Bureau of Apprenticeship and Training, United States Department of Labor. @) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS ‘NAME AND TITLE oO Sarah Harper, Payroll Clark > inaddition to the basic haurly wage sates pald to each laborer ar mechanic theted in the above ‘eferenced payrall, payments of frings benefits 2 listed in the contract THE WILLFUL FALSIIGATIONO FANVO @7 HEABO VEST ATEMENTEM AY GLIBY EOTT TE GO NTRAGTOR O SURCONTRAGTOR Ta CIVi. OR ORIMINAL PROSECUTION, SEE SECTION 1001 OF TITLE 18 AND SECTION ZS OF TITLE have been or willbe made to appropria te progra ms for thebene fit of such employees, except as nated in seation 4(c) below. 31,OF THE UNITED STATES CODE, U.S. Department of Labor PAYROLL SWHE Wage and Hour Division (For Contractor's Optional Use; See Instructions at www.dol.goviwhdiforma/wh347Instr tm) US, Woge nnd Hour Diviston Parsons are not ranuirad te respond to ths collection of information uniass It displays 4 currently valid OMB cantrof naman, Rev, Deo, 2008 NAME GF CONTRACTOR [] __ ORSUBCONTRAGTOR [gy ‘ADDRESS +996 Hidden Terrace Drive Toms No.: 1236-0008 Bi Smith Electric, tne. Cantonment, FL. 92633 Explres; 01/31/2018 PAYROLL NO. ] FOR WEEK ENDING