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

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H6\g y pue wo [B01 | seem ion waloig Jarey fed} jeior rm awen aakojdury (on (6) suononpeg (3) u) @ | syed pue keq —(p) tw) # Nid [Bea Sens G0E——]—uones07 pur r0afoua boz19 #yeqUOD woz TEGO Supuarsemsos [2] <aqUN josKeg 1észe 14 “e0eg snug Aqiag 895] ssauppy L “oul ‘buldesspuey Awouos3] @WEN $40};9eQU0D sien :Psooay JNOH pue abe uononjsuog 69-0L0-002 LVe-HM amy DATE: 31-OCT-12 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- day of that during the payroll period commencing on the 24 OCTOBER 2012, and ending the 30 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 the full any person weekly wages from 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 3145), and described amended (48 Stat. 357;40 U.S.C. Copeland Act, as Stat. 967; 76 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 are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the 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 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, 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 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 benefit of such employees, except as noted in Section 49(c) below. IN CASH (b) WHERE FRINGE BENEFITS ARE PAID 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 required fringe rate plus the amount of the benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS: AUDREY FARAGHER ADMINISTRATOR Jb dus fatash [piswacsre) (Name & Title) 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 uojondjsuog 69-010-002 “A009 SALVLS GALINN SHL AO L€ ATLL JO L€% NOILOAS GNV 81 3TLIL JO L001 NOILOZS AAS “NOLLNDASOUd TWNINIYD YO MAID OL YOLOWULNODENS YO YOLOVYLNOS SHL LOAraNs AVW SLNAWALVLS BAOV SH. AO ANV SO NOILVOISISTV4 INSTHIM SHL { § WEA F i ee R 0 rt LN3AGISSYd ‘YaLYOd H N313H 2Mo|@q (9)p UONDaS UI pajoU Se }deoxa ‘Joes }UCD AY} U! 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