Okaloosa County BOCC — December 18, 2012 — Bob Sikes Airport Taxiway A - Change Order #5, Close-out docs, Final Payment form — reading text

or Subcontractor) from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357; 40 U. S. C. 3145), and described below: NO WORK PERFORMED See attached payroll for a list of deductions (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and compiete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed, (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, of if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS (- In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed 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. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH 0 - Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS: NAME AND TITLE IGNATURE JANICE JOHNS EEO OFFICER pis pho THE WILLFUL FALSIFICATION OF ANY ora ABOVE STATEMENTSATAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR Tove IL OR CRIMINAL PRO; UTION. SEE SECTION 4001 OF TITLE 18 AND SECTION 231 OF TITLE 310F THE UNITED STATES CODE. ay DATE: i7-oem12 I, AUDREY FARAGHER , ADMINISTRATOR (Name of signatory party) (Title) do hereby state: (1) That I pay or supervise the payment of the persons employed by INGRAM SIGNALIZATION, INC. on the ACCI NO:61201 BOB SIKES AIR- that during the payroll period commencing on the 10 day of OCTOBER 2012, and ending the 16 day of OCTOBER 2012, all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said INGRAM SIGNALIZATION, INC. earned by and that from the full weekly wages any person no deductions have been made either directly or indirectly earned by any person, other than from the full wages permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle under the A), issued by the Secretary of Labor 948, 63 Stat. 108, 72 and described amended (48 Stat. 357;40 U.S.C. Copeland Act, as Stat. 967; 76 3145), Stat. below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein less than the applicable wage rates contained in any that the are not wage determination incorporated into the contract; classification set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period or registered in a bona fide apprenticeship program duly registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department State, of Labor, or if no such recognized agency exists in a are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS Y in rates the above referenced payroll, payments of fringe addition to the basic hourly wage paid to each laborer or mechanic listed in benefits as listed in the contract have been or will be made to appropriate programs for the such employees, except as noted in benefit of Section 49(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS : AUDREY FARAGHER ADMINISTRATOR A udus /; WMighe (Signature) (Name & Title) THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL SECTION 1001 OF TITLE 18 AND SECTION 231 OF SUBJECT THE PROSECUTION, SEE TITLE 31 OF THE UNITED STATES CODE. ¥ DATE: 24-OCT-12 Ae I, AUDREY FARAGHER , ADMINISTRATOR (Name of signatory party) (Title) do hereby state: (1) That supervise the payment of the persons employed by INGRAM SIGNALIZATION, INC. I pay or on the ACCI NO:61201 BOB SIKES AIR- that during the payroll period commencing on the 17 day of OCTOBER 2012, and ending the 23 day of OCTOBER 2012, all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said INGRAM SIGNALIZATION, INC. earned by any person and that from the full weekly wages no deductions have been made either directly or indirectly full than earned by any person, other from the wages deductions as defined in Regulations, Part 3 (29 A), issued by the Secretary of Labor amended (48 Stat. 948, 63 Stat. 3145), permissible CFR Subtitle under the Copeland Act, as 108, 72 Stat. 967; 76 and described Stat. 357;40 U.S.C. below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein less than the applicable wage rates contained in any that the are not wage determination incorporated into the contract; classification set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period or duly in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the registered Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS / In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe penefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 49(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH Each laborer or mechanic listed in the above referenced payroll has been paid, as payroll, an amount not less indicated on the than the sum of the applicable basic hourly wage of the required fringe rate plus the amount penefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION me jae, e AUDREY FARAGHER ADMINISTRATOR ZA. uals Petadghe (Name & Title) (Signature) THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF SUBJECT THE PROSECUTION, TITLE 31 OF THE UNITED STATES CODE. LL/LO uoljonsjsuo9 69-010-002 “AGO SALVLS GSLINN SHL dO Le FILIL SO L€% NOILOAS GNV 81 ATLIL AO 1001 NOILOAS AAS ‘NOILNOASONd TWNINIYS YO MAID OL YHOLOVULNODENS YO YOLOVYLNOSD SHL LOAPANS AVW SLNAWALVYLS SAO8V AHL IO ANV dO NOILVOISIS TVS INATIIM SHL roe ate AN3ISSYd “Y3SLYOd H N31SH zmojag (9)p UoIDag Ul payoU se ydeoxe ‘joRsjUOD AY} U! 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JO ANOSuIP Jaye apew aq {IM JO uaaq aAeY sayeqau ou yeu) ‘pauses sabem Ajyaem |/Ny au) pred Udeq aaey yaloud ples UO pafojdwie suosiad |e ZL-PO jo Kep HILL ayy Bulpua pue jo Aep HLbL uj uo BulouawWoo poued jjo1Aed ey) Buinp yeu) (40yDeUODNS JO JOJ}DeNUOD) ‘Aempxe podity saxis qog dy-2S81-119 0102 Z0-vL00-Z-€ uy} Uo “ONT ‘ANWdINOD NOILONYLSNOO YALYOd Aq pafkojduue suossed ayy Jo yuawhed au} asivsadns Jo Aed | yeu (1) :aye}s Aqauey op (en) (Ayed AuoyeuBis yo awen) GSWxYOsAYAd MHOM ON ANSGISSYd YaLYOd H N313H ‘ NOILYNW1dX4 (Lavud) NOLLdIOXA SNOILdS0xa ©) ZeworOCS™ ava :90uel|dwiod jo JUSsUIa}e}S QuYOO3Y YNOH ANV ADVM NOILVLYOdSNVUYL AO LNAWLYVd3d VdIdO1sd 40 ALVLS 700-010-69 Form WH-347 Construction Wage and Hour Record LORIDA 32447 4910 HARTSFIELD ROAD, P.O.BOX 923, MARIANNA Fi Address PORTER CONSTRUCTION COMPANY, INC Contractor's Name Payroll Number: La_] For Week Ending a Employee Name and 4 Digit Identifier (9 digit SS and full address required] ‘on contracts Let prior to 1/19/03) BOB SIKES AIRPORT TAXIWAY omit Project and Location October 17, 2012 Deductions 7) Project Gross 1 Weekly Gross Group _|Total from attached ie @ deduction sheet Exemptions / Race : a Classification Deductions stright / Over Time NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED Date 11/5/2012 (b) WHERE FRINGE BENEFITS ARE PAID