Okaloosa County BOCC — 2013 meeting #1141 (date undetermined) — CW Roberts DTS Rehab RW 14_32 Final Certified Payroll — reading text

UNCLASSIFIED . Department of Homeland Security Report Prepared: 02/28/2015 E-Verify Page: 1 of 1 Case Verification Number: 2013059112083G6C Cane Information: Eesployee Information: Last Name; Mandy Fitst Name; Steven Middle Enitial: J Maléén Nami: Social Seourlty Number, 7" ** 6663 Date of Birth: F122/1980 Citizenship Statux A citizin-of the United States , ; Document iaformation: ae ; so List 8 Dooument: Diver livenge ox con aues byaUS. 5 ict e Document: Social Seourlty. Card Document Name: Driver's leense" Doouniont State: Plorida Driver's Lleease or1P Cara ngaqg79d604220 Doourient Expiration Date: 11/22/2017 Alien Namber: 1-94 Number; Additional Information: Client Nome: Daniel'$, MoClellan Electrical Contractors, Ina, Hire Date: OF12/2001 Smployer Case LD: ; Theee-Duy Rule Reason: «= Other Three-Day Rule- Other: Just setting up B-Verify Sobmitted By: CMOOISL6 Submitted Om: | On28/2013 Initial Case Result: Case Result Employment Authorized Employee Referred to SSA: Reforrad By: , Referred Ons Case Result from SSA (after SSA Tent ative Nonconfirmatton):_ Response Date: Case Resutt: Resubmitted to SSA (after Review and Update Employee Data): Laur Name: First Name: Mhidle initial: - Maiden Name: Social Security Number: Date of Birth Resubmitted By: Resnbmitied On: Case Regult from SSA-(atter Resubmission): Case Result: ~ Request Name Review: Commonts: Subniitted By: Submitted On: Case Result from DHS (after DHS Verification in Process); Case Rekutt: Response Date. Employee Referred-to DHS: _ Referred By: RetersdOn! Case Result from DHS (atter DHS Tentative Nonconfirmation): Case Result: Rosponse. Diate: Photo Matching Results: Determination: https://e-verify.uscis. gov/esp/BpCaseDetailsLetter.aspx?CaseVerNum=20 130591120536C 2/28/2033 Page Z of 2 Employee Referred to DHS (Additional): Referred By: Referted Om Case Result fram DHS (after Additional DHS Tentative Nouconfirmation): Case Result: Response Date: Case Closure: Closure Statement: The eniployes.continues to work for the employer after receiving an Employment Authorized result. Closed By: CMOOISI6 Closed On: 02/28/2013 SENSITIVE BUT UNCLASSIFIED Page 1 of 2 SENSITIVE BUT UNCLASSIFIED Departinent of Homeland Security Report Prepared: 02/28/2013 h-Verify Page: 1 of 1 Case Verification Number: 2013059126342 Case Information: Employee fnformation: Last Name: Ganey First Name: Randall Middle Initial: G Malden Name: i Sociat Security Number: wen ® THED Date of Birth: O5/07/1981 Citizenship Status: A. éiizert of the United Siates Docoment {oformation: . Driver's ficense.or ED card issued by a U.S. List B Document: state or outlying possession List C. Dagument: Sosial Security Card Document Name: Driver's license Document Stabe: Florida Driver's Lleanse or I Card 599727811670 Document Expiration Date: 03/07/2019 Alien Number: 1-94 Number: Additional Information: Client Name: Danial $, McClellan Electrical Contractors, Inc, Hire Dawe: 01/01/2004 Einployer Case YD: Three-Day Rute Reason: Other “Three-Ddy Rule - Other: Just signed up for B- Verity Submitted By: CMOOISIG ” ‘Submitted Op: 0228/2013 Initial Case Result: 7 Caso Result: ‘Amployment Authorized Employee Referred to SSA: Referred By: Referred On; Case Result from SSA (after SSA Tentative Nonconfirmation): Case Result: ” Response‘ate: Resubmiited to SSA (after Review and Update Employee Data): Last Name: Fitst Name: Middle Initial: Maiden Name; Social Security Number: Date of Birth: Resubmitted By: Resubmitted On: Case Result from SSA (after Resubntission): Case Result: Request Name Review: Comments: ; Submitted By: Submitted On: Case Result from DHS (after DHS Verification in Process}; Case Resolt: "Response Date: Employee Referred to DHS: a Referred By: Referred On: Case Result from DHS (after DHS Tentative Nonconfirmation): Case Result: Response Dts; Photo Matching Results: Determination: hitps://e-verify.uscis.gov/esp/BpCaseDetailsLetter.aspx?Case VerNum=201 3059112634JZ 2/28/2013: Page 2 of 2 Employee Referred to DHS (Additional): Referred By: Referred On: Cause Result from DHS (after Additional DAS Tentative Nenconfirmation): Case Result: Response Date: Case Closure: ; Closure Statement: "Tie omployee continuss to work for the cmplayer after revelving an- Employment Authorized result. Closed By: CMOO1916 Closed On: ” 02/28/2015 SENSITIVE BUT UNCLASSIFIED ittps://e-verify.uscis.gov/esp/BpCaseDetailsLetter.aspx?Case VerNum=20130591126342 2/28/2013. Page 1 of 2 SENSITIVE BUT UNCLASSIFIED Department of Homeland Security Réport Prepared: 03/05/2013 E-Verify Page: 1 of 1 Case Verification Number: 2013064120037WK Case Information: Employee Informations Last Name: Henderson First Name: Whitney Middle Initial: B Malden Nawte: Social Security Number: wei eh 946 Date of Bink: 06/LO/1979 Citizenship Status: A citizen of the United States Document Information: - — . List 8 Document: governnent ay by 2.8, federal, state-of focal, ist C Document: Saclal Security Card Alien Number: 1-94 Number: Additional Information: Client Name: Daniel 8, McClellan Electrical Contractors, Inc. Hire Date: 10/30/2012 Employer Case ID; ' Three-Day Rule Reason: Onhier Three-Day Rule ~ Other: Just signing up.for E-Verify Sabmitted By: CMOOIMILG Submitted On: 03/05/2013 Initial Case Results a Case Result: Employnient Authorized Employee Referred to SSA; 7 Referred On: Referred By: Case Result from SSA (after SSA Tentative Nonconfirmation): Case Result: “Response Date: Resubmitted to SSA (after Review.and Update Employee Data): Last Name: First Name: Middle Initial: Maiden Name; Social Security Number: ‘Dats of Births. Resubmitted By: Resubmitted On: Case Result from SSA. (after Resubmission): _ Case Result: Request Name Review: Comments: Submitted By: Submitted On: Case Result from DHS (after DHS Verification in Process): . Case Result: Response Date: Employee Referred to DHS; __ ~ “Referred On: Referred By; Case Result from DHS (after DHS Tentative Nonconfirmation): ss wtmiaaiadediainai Cane Result: "Response Date: Page 2 of 2 Case Result from DHS (after Additional DHS Tentative Nonconfirmation): _ Case Result: , Response Date: Case Closure: Closure Statement: The employee continves to work for the employer after receiving an Employment Authorized result. Closed By: CMOOLIIG Closed On: 03/05/2013 SENSITIVE BUT UNCLASSIFIED RELEASE OF CLAIMS CONTRACTOR’S RELEASE UNDER CONTRACT: KNOW ALL MEN BY THESE PRESENTS: In consideration of the premise and the sum of One Hundred Thirty Nine Thousand Three Hundred Ninety One($139,391.54 J) 2b4 lawful money of the United States of America (hereinafter called the“Govertunent”) Zero MOmnies ($_ 00.00 } of which has already been paidand_One Hundred and Thirty Nine Thousand Three Hundred and Ninety One Dollars and Fifty Four ($139,391.54 ) of which is to be paid by the Government under the above mentioned contract. The undersigned Contractor docs, and by the receipt of said sum shall, for itself, its successors and assigns, remise, release and forever discharge the Government, its officers, agents and employees, of and from all liabilities, obligations and claims whatsoever in law and in equity under or arising out of said contract, except specified claims in stated amounts, or in estimated amounts when the amounts are not susceptible of exact statement by the Contractor, as follows: IN WITNESS WHIEREOF, this release has been executed this 26 day of March 13 WAM ESS08 Washington Painting Services Inc. ’ Ne 7 CONTRACTOR AN) By, Leslie Washington ni, President CERTIFICATE 1 beguue C. fudnesea in? & tay certify that Tam the “4 bes: P eagt / secretary of the corporation named as Contractor in the foregoing telease: that. Leéuie / Vlagaiwere, who signed said release on behalf of the Contractor was then APs iD AL of said corporation: that said release was duly signed for and in behalf of said corporation by authority of it’s governing body and is within the scope of its corporate powers. CORPORATE SEAL b STATEMENT OF COMPLIANCE PAYROLL NUMBER PAYROLL PAYMENT DATE CONTRACT NUMBER 1 4-3-13 to 3-23-13 a _ a Date_3. 96-43 1Leslie Washington Pres. do hereby state (Name of signatory parly) (Title) (1) That I pay or supervise the payment of the persons employed by Washington Painting Services Inc. (Contractor or Subcontractor} onthe R / W Destin Airport , that during the payroll period commencing onthe 3 day (Building or work) Feb 20 13 and ending the 23 dayof_ March 20.13 all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made cither directly or indirectly tooronbehalfofsaid Washington Painting from the full weekly wages earned by any person and that <=, _ (Contnetor or subcontractor) Services Inc. no deductions haye been made either direcily or indirectly from the fill 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. 276c) and described below: NONE (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 the 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 dully 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. (4) That: CE (@) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR PROGRAMS In addition to the basic hourly wage rates paid to each taborer or mechanic listed in the above referenced payroll, payments of ftinge 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() below. MN (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 arnount not fess 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 NONE NONE REMARKS 2 i “~ b Leslie Washington Pres 4 U2 Cuke SIGNATURE a NAME AND TITLE ‘The willful falsification of any of the above statements may subject the Contractor or subcontractor to the civil or criminal prosecution, See Section 100) of Title 18 and Section 231 of Title 31 of the United States Code. 02/11/2013 AMERICAN STRIPING Page 7 1:40 pm Certified Payroll Report For Pay Period Ending 02/09/2013 Group Code 0 Job 1304 DESTIN AIRPORT WASHINGTON PAINTING Employee Hrs, 2/3 ala 2/5 afG 2/7 af a9 Pay Rate Gross Wages Address Type *Sun* *Mon* *Tuet #Wed* *Thut *Fri*t +#Sats Total Job Total Tax W/H Net Pay 067 SSN: R 7,000 7.000 13.870 FWH 182.90 1087.09 LAYMAN, TYLER D 0 000 OAS 67,40 774,83 3135 N. BEGOLE RD, D 000 97.09 MED 15,76 ALMA ,MI 48801 M 000 SWH MI 46.20 Other State: 00 Other Pay: 00 Total Ded: 00 Single (0) Sex: Male EEO= White Class/Level/Skill: SWEEPER DRIVER 70 072 SSN: R 4,000 4.000 12.000 FWH 236.90 1303.09 GUSTAVISON, TIMOTHY D 0 000 OAS 80.79 911.12 1161 N. RICH RD, D .000 48.00 MED 18.90 ALMA ,MI 48801 M 000 SWH MI 55.38 Other State: 00 Other Pay: .00 Total Ded: 00 Single {0} Sex: Male EEO= White Class/Level/Skill: MAINTENANCE 50 067 SSN: 000 18.000 FWH 182.90 1087.09 R LAYMAN, TYLER D 0 8.000 8.000 OAS 67.40 774.83 3135 N. BEGOLE RD. D . 000 144.00 MED 15,76 ALMA ,MI 48801 M 000 SWH MI 46.20 Other State: 00 Other Pay: