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

IN CASH I JANICE JOHNS EEO OFFICER (1 - Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the (Name of Signatory Party) Title) 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 do hereby state: Section 4(c) below. (1) That | pay or supervise the payment of the persons employed by ANDERSON COLUMBIA CO., INC. (c) EXCEPTIONS (Contractor or Subcontractor) on the Job: 6120+ TAXIWAY A,BOB SIKES AIRPORT, : EXCEPTION (CRAFT) EXPLANATION } (CTETSSZAB adealinel- 022-200 that during the payroll period commencing on the 21 dayof _ October, 2012 , andendingthe __27 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 ANDERSON COLUMBIA CO., INC. (Contractor 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 REMARKS: (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 are not less than the applicable [\jAME AND TITLE TURE. — wage rates contained in any wage determination incorporated into the JANICE JOHNS contract; that the classifications set forth therein for each laborer or mechanic | EEO OFFICER ba 2 e. ¢ Conform with the work he performed: THE WILLFUL FALSIFICATION OF ANY OF ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO f#iL OR CRIMINAL PROSECUTION. SEE SECTIO! 1001 OF TITLE 18 AND SECTION 231 OF TITLE 310F THE UNITED STATES CODE. (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. Date 11/7/2012 \, JANICE JOHNS (Name of Signatory Party) EEO OFFICER Title do hereby state: (1) That | pay or supervise the payment of the persons employed by ANDERSON COLUMBIA CO., INC. (Contractor or Subcontractor) on the Job: 61201 TAXIWAY A,BOB SIKES AIRPORT, : (CTETSSZABitadeatWolq 022-2070 that during the payroll period commencing on the 28 day of October | 2012 and ending the 3 day of November 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 ANDERSON COLUMBIA CO., INC. (Contractor 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: 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 complete; 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 - 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 JANICE JOHNS EEO OFFICER | THE WILLFUL FALSIFICATION OF ANY OF J} MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO ‘CUTION. 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