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

STATEMENTS MAY THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF SUBJECT PROSECUTION, TITLE 31 OF THE UNITED STATES CODE. PAGE: 26 DATE: 26-SEP-12 12:59:40 INGRAM SIGNALIZATION, INC. COMPANY: 1 (01) (This Substitutes For: WH 347 / U.S. Department of Labor Wage and Hour / Public Contracts Division) (P63378) PAYROLL NO: 0000 PROJ: 1135 CONTRACT #: 61201-1462 CUST: ANDERSON COLUMBIA CO, , INC WEEK BEGIN: 9/19/2012 NAME: ACCI NO:61201 BOB SIKES AIR- ADD1: 4522 NORTH DAVIS HWY ADD1: P.O. BOX 1829 WEEK END: 9/25/2012 LOCN: BOB SIKES AIRPORT TAXIWAY A ADD2: PENSACOLA FL 32503 ADD2: LAKE CITY, FL 32056 FEISS OCI IGE ITC GGG CSSSE GEG GGEG ISIC GCE IIE IRIE ir EMPLOYEE 4 DIGIT - FIT FICA LOCAL GROSS NAME & ADDRESS ID WED THUR FRI SAT SUN MON TUES TOTAL SIT cIT DEDUCT OTHER RATE ie 20 21 22 23 24 25 sur SDI REIMBURSE NET FEC CSC SIG CSCC OG GGII III IGG GCCCCGG GGG EGCG SIG IIIT IIIS GG ioe JEFFERY SCOTT ALLEN 5542 Sex: M Race: W 2-00 Class: ELECTRICIAN Craft: R 11.00 11.00 11.00.00 .00 7.00 .00 40.00 172.36 58.54 .00 1,093.75 Oo .00 .00 .00 .00 .00 4.00 11.00 15.00 .00 -00 60.58 -00 REG: 17.500 OVT: 26.250 GROSS: 1093.75 -00 00 -00 802.27 JES CO SSS SO USSU SSISSHEBeSbEEbHbbE DEDUCTION DETATIS (OUCH CG GCHEO HE EHOHE SSDS EEESE Sor EEE PRE TAX HEALTH 52.64 | PRE TAX DENTAL 4.94 | UNIFORMS 3.00 | MARC JACOB HUGHES 2293 Sex: M Race: W 2-00 Class: GENERAL LABOR Craft: R 11.00 .00 11.00 .00 .00 .00 .00 22.00 113.12 45,16 .00 819.00 © .00 .00 .00 .00 .00 6.00 .00 6.00 -00 .00 215,47 00 REG: 14.000 oOvT: 21.000 GRoss: 434.00 00 -00 -00 445.25 JOSE SSIS SSS SIC HOSS OTE OH HHEOEE: DEDUCTION DETATLS CHUGH OCHO EHCEGEG ESO Snob HERS PRE TAX DENTAL 19.80 | LIFE INSURANCE 1.36 | COURT 191.31 | UNTFORMS 3.00 | JOHN D. PAINTER, JR. 3688 Sex: M Race: W 1-04 Class: GENERAL LABOR Craft: R 11.00 11.00 11.00 .00 .00 7.00 .00 40.00 11.44 31.79 -00 562.50 . 0 .00 .00 .00 .00 .00 4.00 11.00 15.00 .00 00 -00 -00 REG: 9.000 Ovr: 13.500 GROSS: 562.50 -00 .00 .00 519.27 JOB TOTALS: FIT: 296.92 FICA: 135.49 SIT: -00 cr: -00 SUI: .00 SDI: .00 DEDUCT:: 276.05 GROSS/ALL: 2,475.25 9 NET: 1,766.79 REIMBURSE : -00 REG HOURS: 102.00 OVT_ HOURS: 36.00 LOCAL: .00 WORK DEV: .00 OTHER: .00 GROSS/JOB: 2,090.25 STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION WAGE AND HOUR RECORD Statement of Compliance: DATE 09/27/12 (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION I, HELEN H PORTER PRESIDENT (Name of signatory party) (Title) do hereby state: (1) That | pay or supervise the payment of the persons employed by PORTER CONSTRUCTION COMPANY, INC. on the 3-12-0014-022-2010 611-1862-AP BOB SIKES AIRPORT TAXIWAY A REHAB, (Contractor or Subcontractor) (Bi ing or work) that during the payroll period commencing on the 20TH day of Sep-12 and ending the 26TH day of Sep-12 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 REMARKS: PORTER CONSTRUCTION COMPANY, INC. from the full weekly (Contractor or Subcontractor) 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 40 U.S.C 31 45), and described below: FICA, FEDERAL WITHHOLDING, MEDICARE, GRP.INS, CHILD SUPPORT NAME AND TITLE SIGNATURE (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 ladorers 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, 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. [Jin 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. (0) WHERE FRINGE BENEFITS ARE PAID IN CASH k Each laborer or mechani ted 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: f HELEN H PORTER, PRESIDENT \\ iy) F 4A own pst THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED STATES CODE. 700-010-69 Construction 01/11 Deduction Record: Contractor's Name PORTER CONSTRUCTION COMPANY, INC | Address [- 4910 HARTSFIELD ROAD, P.O.BOX 923, MARIANNA FLORIDA 32447 | 700-010-69 Construction Payroll Number: [ ma | For Week Ending September 26, 2012 Contract # 01/11 FIN # | 3-12-0014-022-2010 C11-1852-AP| Project and Location BOB SIKES AIRPORT TAXIWAY A REHAB. Employee Name CHILD SUPPORT Pho CHARLES T NELSON II $0.00 ROLANDO G SANCHEZ $0.00 ROBERT B BOOTH $0.00 DEVIN J WARD $0.00 MINGO H HENDERSON $0.00 SEBASTIAN D VELASQUEZ $0.00 JULIO C GARZA $0.00 JOHN D MICKEL $0.00 MARROQUIN D GODINEZ $0.00 DANNY F LIPFORD $175.08 $175.08 REGINALD R MCNEALY $141.48 $141.48 ERIC D CLARK $0.00 NAEL H MORALES $0.00 WYNN J SANDEFUR $0.00 SANTIAGO L PEREZ $0.00 Date 10/11/2012 EEO Officer (Title) I, Janice Johns (Name of Signatory Party) 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: 6120+ TAXIWAY A,BOB SIKES AIRPORT, ; (CTFISSZAR aes 022-2010 that during the payroll period commencing on the 23 day of _September 2012 , and ending the 29 day of September 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 O- 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 Ww: 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 LSIGNATURE : Janice Johns OF EEO Officer ALLL. — CONTRACTOR OR SUBCONTRACTOR TO GIVI OR CRIMINAL PROSECUTION. 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