Bowers CP 1 and 2_Redacted C lifornia 2022 Bowers&Sljou 2/3 Waterline Replacement Project 120.30.8094 aid 20_30.8281
il . pepertrnent of
IndustrialRelatians id
PUBLIC WORKS PAYROLL REPORTING FORM Page 1 of
INAMF OF CONTRACTOR:Vinciguerra Construction,Inc. CONTRACTOR'S LICENSE NO.:358638 ADDRESS:P.0.Box 157,Sutter Creek,CA,95685
!OR SUBCONTRACTOR: SPECIALTY LICENSE NO.;
1PAYROLL NO. FOR WEEK ENDING: SELF-INSURED CERT: PROJECT OR CONTRACT NO.:20.30.8094 and 20,39.5281
] 1 4/2312022 WORKERS'COMP: •PROJECT AND LOCATION!2022 Bowers&Bijou 2/3 Waterline Replacement Project,EL17
(1) (2) I (3) (4)DAY (5) {6) (7) ($) (9)
T WITFS
NAME,ADDRESS 22 I ACT
AND SOCIAL 92 WORK Date TOTAL HOURL GROSS AMOUNT
ACES CHECK( CLASS-;S- } r ROTE DEDUCTIONS,CONTRIBUTIONS AND PAYMENTS PAD
SECURITY NUMBER 62i r HOURS EARNED NO.
Es. ( IFICAT ION 4.07 4r18 409 4120I 4121 4122 4123 OF PAY FOR
OF EMPLOYEE 3x 1 WEEK
} Haws Worked Each Day
I THIS ALL Fede!aE FICA& / State Vat Con Health&
S 0.00 5.00 0.00 0.00 0.00 0_00 0.00 5.00 $48.50 PROJECT PROJECTS Tax Medicare Tax SDI Holiday Welfare Pension
SABIA,MORGAN IPLUMBER/ 5130.00 593 69 $53.07 $13.48 $000 50.00 50.00
1111. 0 I
N DUTILlT 0^ 0.00 0.00 0.00 0.00 0.00 0.00 0.0A'1 0.00. $83.95 $934.48. 3452
I ND UTILITY Admtn f Travel& Total
( PIPEFITTER $242.50 $1.228.22 Training Fringes Oues Sub Savings Other Total
I 13 0.00 0.00 0.00 0.00 o.en 0.00 0.09 0.00 50.00
$2.00 $0.00 50.00 $0.00 50.00 S3.59 5293.74
'
r.___
Other Deaucion Notes:Trainino fee
THIS ALL Federal FICA& Slate Vacation Health&
I S ODD 5.00 0.00. 0.90 0.00 0 00' 0.00 5.00 $82.84 PROJECT PROJECTS Tax Medicare Tax SDI Holiday Welfare Pen&Ion
LINCIGUERRA. I Operating - - $249.00 $177.12 $158.53 $25.47 $0.00 $0.00 $0.00 •
1 Engineer $108.3
2 (Heavy& 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 - $1,705.17. 3454
Highway work)/ 0I Ad
rnin t Travel S Total
Group 3 Area 1 - $41d.20 $2,323.85 Training Fringes Dues Srsb Savings Other Deduct.
( D 0.00 0.00 0.00 0.00 0.00 0.00• 0.00 0.00 $0.00 $6.35 $0.00 $0.00 $0.00 $0.90 $9.58 $618.68
I
Other❑educdvn Ndes:Training fee
S=STRAICNT TUBE 'OTHER-Any other dedudron5.conrrirwt;ons ardier payments wheeler or nol included or required by Pevaiueg wage delemmrialwas most be separately 4eled. CERTIFICATION MLSI be Campkl[ad
0=OVERTrME use extra sheer(e)if necessary, (See reverse ride}
Form Ar1-131(New 2-80) a=DOUBLET IME
gpl a STATE DISABILITY INSURANCE