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

SECTION. have been or willbe made to appropria ta progra ms for the bene fit of such employees, except as noted In eacllon 4{o} below. SHOP THE UNITED STATES CODE, TRACTOR R 231 OF TITLE, U.S. Department of Labor PAYROLL : Swi Wage and Hour Division (For Contractor's Optional Use; See Instructions at www,dol.goviwhdlforms/wh347Inatr.htm) US, Waye and Hay Dion Porsons are not required to respond to the collection of information uns it deplays a currentiy valid OMB control number Rev, Dec, 2008 Waniz GF CONTRACTOR [-] __ OR BUBCONTRAGTOR fy] TADORESS 956 Hidden Terrace Drive | ou Na, 23s 9008 Bill Smith Electric, ine. Cantonment, FL 32533 PAYROLL No. T For Weex eNoIne PROJEGT AND LOCATION PROJECT OR CONTRACT NO, 36 4210812012 NWF Raglonal Airport Rehab Public Parking . | Fagllties, Okaloosa County 612-1939-AP cy (a a) (4) DAY AND DATE: 6) 48) 7) @ (8) Be i MI] T] wits) F]s1s DEDUCTIONS er NAME AND INDIVIDUAL IDENTIFYING NUMBER fy, & ross wT wits (eg, LAST FOUR DIGITS OF SOCIAL BEOURITY Ff] WORK BL] 4] 5 | 6) 7] 818 tora] pate AMOUNT Houpine | MEP | care Or PAID NUMBER) OF WORKER g CLASSIFICATION CRS ORREDERCTOAY Hours! orpay | eaRNeo | ica | tax omer _joecuctions| ror week Travis Tucker 4377 Electictan fo 565.28 1 $30.42 | $55.00 | $36.33 9122.25 $453.00 J 500 5.00] 17.03 $575.25 Henry Black 1448 Electician fo 885.28 1 33652 | $76.00 | $4557 $189.09} $533.91 8 vas a 3.00 $653.00 eo A o 5 ° jo ® ° A ° 2 “The Copeland Act ssled consirucion conivacla lo respond (a te Information oofeclon oartalned in 24 C.F. Bai ant wit respect fo Ine wages pelt aach amploysa during the praceding Week.’ U.S. Department af Labor (DOL) cegutstiona at alcating thal the payrott are correct and complete and that sch laberer ‘Wille completion of Form W347 a eptonal ts mandatory for overed contracloa and subaontegctoreparforming weik on Fedorally finance (40 U.S.0, € 3145) contactors and aubceriractoss peroming Wark on Pedarally hanced ot agssted canstrucion cartracte lo Tumish Weekly @ 2OC.FAR. 8 5.8(6}(9) require contractors to aubmit wostly & copy of ll payrois fo the Faderal agency contacting fr er Anancing the conetruction project, aecompardad by a signed "Slatsraant af Compliance’ ‘or machanta haa been palé not tess than the proper Davis-Bacen prevaling wage rals fer tha work parfonmed. DOL and federal contracting agancias raceving this Information reviav the infoimalion fo delacnine hat employees have received legaly required wages and finge benoit, Publle Burdan Statement ‘We satimato inl is wil eke an averaga of B6 minutes to complete the collection, neuding fe for reviewing Instructions, searching axisting data sourcos, gathering and maintening the data needed, and complalng and reviewing the catcton offafommation, Ifyou have any comments regarding tnésa estimates or ary einer agpsct of thi colectin, inducing suggestions for seducing this burden, send tham fo Iho Adminstator, Wage and How Dvilon, U.S. Dapartmant af Labor, Room $9802, 200 Conaltuion Avenue, NN, ‘Washington, D.C, 20210, ora 700-010-869 STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION Construction WAGE AND HOUR RECORD Statement of Compliance: DATE December 12, 2012 (c) EXCEPTIONS. EXCEPTION (CRAFT) EXPLANATION. 1 Mary Ann Scurlock {Name of signatory party) ites do hereby state; (1) That | pay or supervise tha payment of the parsons employed by Guettler & Guetler, Inc. ‘on the FIN #C42-1805-AP ‘(Contractor or Subcantrentor) ‘(Bufteing or work} that during the payroll pertod commencing on the 2nd day of December and ending the ath dayof © December all persons amployed on ald project have been paid the full weekly wages eared, that no rebates have been or will be made elther ditectly or Indiectly to or on behalf of sald Guettler & Quetlir, Inc. {Contractor or Subcontractor) wages eamied by any person and that no deductions have been made either dlrectly or Indirectly from Ihe (ull wages eamed by any person, other than permiselbie daductions as defined in Regulations, Part 3 (28 CFR Subllis A), Issued by the Secretary of Labor tinder the Copeland Act, as amended (48 Stat, 048, 85 Stat. 108, 72 Stat, 987; 78 Stat. 367; 40 U.S.C. 9146), and described below, REMARKS: from the full weekly FiCA, Withholding Tax, Medicare, Child Support INO WORK NAME AND TITLE SIGNATURE. (2) That any payrolls otherwiee under this contract required to ba submitted for the above af LE period are correct and complete; (hat the wage rates for laborers or mechantcs contained therein are not Mary Ann Scurlock wal Qs aps fo (ase than the applleabte wage rates contained in any wage determination Incorporated inta the contract; THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE that the classifications set forth therein for each labarer or mechartlo conform with the work he performed, STATEMENTS MAY SUBJECT THE CONTRACTOR OR (3) That any apprenticas employed In the above parlad are duly registered in a bona fide SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE apprenticeshlp program registered with a Stale apprenticeship agency recognized by the Bureau of SECTION 1001 OF TITLE 48 AND SECTION 234 OF TITLE 31 OF Apprenticesh|p and Training, United States Dapartment of Labor, or If no such racognized agency exists THE UNITED STATES CODE, tna State, are registered with the Bureau of Anprentleaship and Tvalning, United States Department of Later. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR PROGRAMS cs addition to the basic hourly wage rates paid fo each laborer or mechanic tisted In tha shove referenced payrol, payments of fringe henefs as Usted In the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4(c) below. (bo) WHERE FRINGE BENEFITS ARE PAID iN CASH [x Jeach taborer or mechanic listed inthe above referenced payroll has been ald, as Indicated on the payroll, an amount not less than the sum of the applicable baste hourly wage rate plus the amount of the required fringe benefits as sted in the contract, except as noted in Sectton 4(a} below: wad Wage and Hour Record: Contractor's Namo rov-s10-69 CConetructon ott Project and Location RFT Regional Aiport Payroll Numbor: [CTECT] Fer weok ening Dagarber 8, 7012 ay 7 (8) Deductions (3) (10) aoe, ne name SaaS] aa atta | tonton (9 digit 88 and full addrase 1 Waeily Deduction | Deductions | “week nge Benet Toqulred on sontrents Lat | (2) oy rose Shoot {attached) prior to HB/08) Examptions / {Work Clagelf-] > fatlached} Wiite/Male Foreman |S $0.00) $ = exx-Kx.0927 whitertiaja | Foreman $0,00) $ - | XXX-XX-7422 WhitesMals Foremart $0.00, § ~ KX KK 268 whiteyttala | —__siriping $0.00) = XK XK98O? BlackMale $0.001 § = Lox-xx.0540 Whitetfiale | Nozzleman $0.00| < [RXX-XX=4111 $0,001 - |XXX-KX-9048 Laborer, $0.00) $ = [XXXXX7846 White/tdale. Laborer, $0.00) $ =. |KXX-KX-0298- White/Malo. Laborer $0,001 $ = [XXX-XX-B6B7_ WhiteMate. Laborer $0.00) $ “ Date 42/20 Alfison M Clark. Secretary (Name of Signatory Party) Title) do hereby state: (1) That | pay or supervise the payment of the parsans employed by INTEGRATED SYSTEMS OF FLORIDA, INC, cathe Contactar oF Sibeontractar} NWFL REGIONAL AIRPORT PKNG LOT REN that during the payroll petlod commencing on the Gullding or Wark) (b) WHERE FRINGE BENEFITS ARE PAID IN CASH {Z] ~ Each laborer or mechanic IIsted In the above referenced payrall hes been pald, as Indicated on the payroll, an amount not less then the sum of the applicable bbasla hourly wags rate plus the amount of the required (ringe benefts as listed In tha contract, excepl as notad In seotion 4{c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) ‘EXPLANATION 8 yor 122012 and ending the 18 day of 12 2012 all persons smployed on sald project have besn paid the full weekly wages earned, that no rebates have been or wil be made ellher direclly or Indirecly to ar on behalf of sald INTEGRATED SYSTEMS OF FLORIDA, INC, (Contractor or Subcontractor) from the full weekly wages earned by any parson and that no deductions have baer made either dlreclly ar inlrestly from the full wages earned by any person, olher than permissible deductions ag defined In Re ns, 63 Start. 108, 72 Stat, 967; 76 Stat. 387; 40 U.5.C, § 3145), and described below. Federal Withholding, FICA, and Insurance (2) That any payrolls otherwise under this coniract required lo be submitted for the above perlod are corrsot and complete; that the wage rates far laborers ar machanics contained therain are not fess than the applicable wage ratas contained In any wage determination incorporated info the contract; that the classifications set forth therein for each laborer or machanic conform with the work he perfarmed. (3) That any apprentices employad in the above perlod are duly ragistered in a bona fide appraniiceship program registered with a State apprenticeship agency recognized by the Buresu of Appreniicaship and Training, United States Department of Labor, ar Ifo such Tecognized agency exists Ina Slats, are registered with the Bureau of Apprenticeship and ‘Training, United Statss Department of Labor, 4) That: () WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS. TT i adalton to the basic houtly wage rales pald fo each laborer ar mechanle listed In the above referenced payroll, payments of fringe benefits as ilsted la the contract have bean or will be made to appropriate programs for the benefit of such ‘emptoyass, except as noted in section 4{c} belaw, , Part 3 (28 C.F.R, Subtitle A), Issued by the Sacretary of Labor under the Copeland Act, as emended (48 Sil. $48, REMARKS; ARIE AND TITLE ALLISON M CLARK ‘SIGH Yi -— SECRETARY ( THE WILLFUL FASIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE GONTRAGTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SEGTION 1001 OF TITLE 18 AND SECTION 231 OF THLE 31 OF THE UNITED STATES CODE, U.S. Department of Labor PAYROLL Wage and Hour Division (For Contractor's Optional Use; See instructlans at www.dol.gov/whd/forms/wh347Instr.htm) USS. Wage and Hour Divlelon Rev. Dac, 2008 Persons are not required to reapand to the caltection of information uniess It displays a currently valid OMB control number. WAMEOF CONTRAGTOR [-] __ OR SUBGONTRAOTOR [yy] ‘ABDRESS 459 SCARLET BLVD, OLDSMAR, FL 34677 QW Now. (215.0148 xplras: INTEGRATED SYSTEMS OF FLORIDA, INC. . PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION: PROJECT OR GONTRAGT NO. 34 sans2012 NWEL REGIONAL AIRPORT PKNG LOT RENO orm a [cy a {4) DAY AND DATE. 6) 6) fal ® (} 9 . JTIONS a2 &/ s|m[t[w[t]F[s beouario} yer NAME AND INDIVIDUAL IDENTIFYING NUMBER | 3 8 GROSS WT beD WAGES (og. LAST FOUR DIGITS OF social secuRITY | 5E, work SL 9 [to fief 12 | 13 14 | 15 bra AMOUNT HOLDING pep Total | PAD AUNBER] OF WORKER, $50] CLAssiFicATION (OURS WORKED EAGHDAY—WoURs} orpry_| tanneo_| rion | "tax oTuen _[peDuCTIONS| FOR WEEK 474,83 HAZELTINE, JEREMY 08-50-9996 ELECTRICAIN |o 8474 2807 BANNER STONE CT 2 5158.03 | $123.03 S23 3280.19. | $1,040.91 HOLIDAY, FL 34691 8 se s.00 19.54 2435 1,321.10 BADALATY, TROY 305-88-5662 ELECTRICAIN |o 8448.50 2826 HILLSIDE RAMBLE DR 2 877.91 | $178.36 $235.66 | $491.93 | $945.57 BRANDON, FL 33511 a 8 vusol seo] | 19,54) 220 Sons 3 ° . ° ° ° s o 3 ° 3 Wile emrlatin of Farm WHLSA7 enol Tor covered and eu ‘work on Federally inenced or assisted construction contracts to respond tothe Information callectlon containad tn 28 C.F.R. $6 3.3, 8.5(a) The Copetand Act 40 145} contractors and subcontractors performing work on Federally financed or assisted -sonetructlon: contracts to furnish weekly a statement with raspact to the wages pald each emplayae during the preceding week.” U.S, Gepartmont of Labor (DOL) regulations at SCHR S sHoHA NN rogue enol fo sl ooh copy el pane Ear egy 319 fr or fnanetng the reject, bya signed Of Complanes Inccating that the payroll rs correct and completa and tat each Iborer agencies rcshng his revi tho to deter that ave evelvedlepaly nur wages and tinge