2021090710301037209-21 Keller Water Storage Improvements Project / 09-21 Keller Water Storage Improvements Project
U.S. Department of Labor PAYROLL
Wage and Hour Division (For Contractor's Optional Use; See Instructions at,dol.govlwhd/forms/wh347instr.htm)
Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Rev. Dec. 2008 aN N a
U.S. Wagc and Hour Ditiuion
NAME OF CONTRACTOR ® OR SUBCONTRACTOR ® (ADDRESS: OMB No.: 1235-0008
Creekside Electrical Contractors, Inc. 3059 Airport Rd., Carson City, NV, 99706 Expires: 7/31/2024
PAYROLL NO. FOR WEEK ENDING: PROJECT AND LOCATION: I PROJECT OR CONTRACT NO.
3 8/25/2021 09-21 Keller Water Storage Improvements Project, CA 09-21 Keller Water Storage Improvements Project
(1) (2) (3) (4) DAY AND DATE (8} (8) (7) (81 (9) .
Thu Fri Sat Sun I Mon Tue Wed DEDUCTIONS
ao
NAME AND INDIVIDUAL ir
°
IDENTIFYING NUMBER 3� `o
08119 0820 0821 0822 08/23 o8/24 0825 NET WAGES
LAST FOUR DIGITS OF SOCIAL o 6 WORK STATE LOCAL TOTAL PAID FOR
SECURITY NUMBER CLASSIFICATION TOTAL OF WORKER RATE OF PAY GROSS AMOUNT FICA HOLDING TAX TAX OTHER DAOuC WEEK
4� HOURS WORKED EACH DAY HOURS EARNED TAX AO
SANTOS, EDMUN ELECTRICIAN / INSIDE
38U WIREMAN S 0.00 0.00 0.00 0.00 0.00 4.00 0.00 4.00 $58.61 / $0.00 $234 44
1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 $0.00 / $0.00 78.63 83.00 38.04 0.00 142.60 342.27 685.49
D 0.00 0.00 0.00 0.00 o.00 0.00 0.00 0.00' $0.00 / $0.00 $937.76
While completion of Form WH-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3. 5.5(a). The Copeland Act (40
U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "famish weekly a statement with respect to the wages paid each employee during the preceding week" U.S. Department of Labor (DOL) regulations at 29 C.F.R.
§ 5.5(a)(3)(0) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for orfrnaneing the construction project, accompanied by signed "Statement of Complianeindicating that the payrolls are correct and complete and that each laborer or
mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits.
Public Burden Statement
We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing Instructions, searching existing data Sources, gathering and maintaining the data needed, and completing and reviewing the col ecdon of information. If you have any
comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room 83502, 200 Constitution Avenue, N.W. Washington, D.C. 20210
(over)
Page 1 of 2
09 21 Keller Water Storage Improvements Project / 09-21 Keller Water Storage Improvements Project
Date: 8/26/2021 (b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Jennifer Andrews President ®— Each laborer or mechanic listed in the above referenced payroll has been paid,
(Name of Signatory Party) (Title) 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
do hereby state: the contract, except as noted in section 4(c) below.
(1) That I pay or supervise the payment of the persons employed by
Creekside Electrical Contractors, Inc. on the (c) EXCEPTIONS
(Contractor or Subcontractor)
EXCEPTION (CRAFT) EXPLANATION
09-21 Keller Water Storage Improvements Project
that during the payroll period commencing on the
(Building or Work)
19 day of August 2021 and ending the 25 day of August 2021
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
Creekside Electrical Contractors, Inc. from the full
(Contractor or Subcontractor)
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 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat 948,
63 Stark. 108, 72 Stat 967; 76 Stat. 357; 40 U.S.C. § 3145), and described below:
Permissible deductions: 13.5% of Gross Wages to Vacation Fund, plus LMCC
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 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
nx - 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.
NAME AND TITLE SIGNATURE
t
Jennifer Andrews, President
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY
SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO dVIL OR CRIMINAL
PROSECUTION. SEE SECTION 1001 OFTITL€A8 AND SECTION 231 OF TITLE 3729
OF THE UNITED STATES CODE_
Page 2 of 2
9/2/2021 eCPR Form Application
Your payroll submission request has been processed.
Please review the results of your submission. Should you have any questions please contact the eCPR unit at
publicworks@dir,ca.gov.
Contractor Name: CREEKSIDE ELECTRICAL CONTRACTORS, INC.
Contractor Address: 3059 AIRPORT RD. CARSON CITY NV 89706
Awarding Body: SOUTH TAHOE PUBLIC UTILITY DISTRICT
Project ID: 371032
Contract With: WHITE ROCK CONSTRUCTION, INC.
Week Ending Date: 2021-08-25
Payroll Number: 3
Amendment Number: 0
1 employee payroll record(s) processed
Your Transaction ID is: 11972856
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