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20211012135451034_Redacted
Public Works Certified Payroll Reporting Form artiffeatlon under penalty of pedu+y: "I, FRAN ;ARM, the undersigned, am the CFO (position in business) with the authority to act for and on behalf of SAN JOAQUIN ELECTRIC INC [name of business andlor contractor), cer[ify under penalty of perjury that the records or copies thereof submitted and consisting of eertifled payroll records for the week ending 2021-09-28 are the originals or true, full, and correct copies of the originals which depict the payroll record(s) of the actual disbursements by way of cashr check, orwhateverfarm to the individual or individuals named, I cartii this on 2021-09-30." ontractor Name: SAN JOAQUIN ELECTRIC INC Contractor PWCR: 1000002857 License Type: CSLB License Number 410103 ddress: 2342 TEEPEE DRIVE, STOCKTON, CA OS213 FEIN: 942753280 Contractor Email: FR4N@SANJ0AQ1JINELECTRIC.CON1 isurance Number: warding Body. SOUTH TAHOL PUBLIC UTILITY DISTRICT DIR Project ID: 371032 Project Name: KELLER-HEAVENLY WATER SYSTEM IMPROVEMENTS PROJECT, PHASE 1 REBID ontract With. CREEItSIDE ELECTRICAL CONTRACTORS, County: EL DORADO Address_ HEAVENLYVALLEY NEIGHBORHOOD, SOUTH LAKE TAHOE, CA 96150 INC, ayroll Number: 1- 0 For Week Ending: 09128/2021 Is this a *Statement of Non -Performance?' Number Day Deductia❑s, Cantributians, end Paymvrrts ll Name, Address and of Soda! Seca Number at Worker 41thholdirig 'Ned Thu Fri Sat Sun Mar, Tue Gross Amount FeCeral Stale '•!ac! Hea!!l� Net }} Q fate Famed Tax FICA Tax SDI Hvliday a Wolf. Pension Wag® Check EOMI]NSAtVT0.S F To!af Nougy work a9122 09123 09124 0!NZ5 09r26 09127 03128 Haurs P@v Ralo -h,y All 185.06 1,4S.75 0.00 0.00 6_00 15840 ?30,00 Paid For Number 1345 CAHI CIRCLE II lfic Classa[ion h Day yoursrke Wod Each _ project Projects Weak GARDNEMLLE INSIDE S 8.00 8.00 0.00 0.00 0.00 0.00 4,0Q 20_QO 5,.54 9. 1.190.80 1,905.28 Fund Tray! Total 1,282.26 17055 NV WPEhiAN Training Adr,in Nias 5Jl 5 Sftvings other Deduct "CREMAN [] 0.00 0.00 Q.K 0,1511 0.00 0.00 0,00 0.00 8e.31 69480 25.00 0,00 Q,o(l 9.00 0.04 49.72 333,81 D 0.00 "0 0,00 0.00 0.00 '"0 0.00 0.00 119.06 VOTE: auhli-'r,•orks corti`)ed Payroll Reporting Form 09J30/20Z1 -Page 1 1 Name, Address and Social Securky Number of Employee Santos, Eamon F 13A5 Cahi Clrcle sass t'wmarnat tn,.rzam Gaffomia PUBUr—WORKSPAYROLL REPORTENG FORM �i Deppaartment of Reladons Page 1 of 1 Industrial Name of Contractor. San Joaquin Elec io Im Contractor License No: 41C1M3 Address: 2342 Teepee Drive PO Box 30M o r S u be ontracto r Specialty license Nw. Stockton, CA 95213 payroll No: 1 1FarWeek Ending; 09Qa2Z SaltaosuredCartlf=tuNo, Project or contract No: Workere' Comp. Policy No_ Project and Location: 21=-K9Wr Heavenly PRV (4) Day c5i is} � } IWITHIFISIS MIT NoDate cbsslfi:af Net Wgs Check Earn I0912ZI08123IOg1i4I0912708128I48127i0912BI Hours Ramey Croas�ount _ Deductions, Contributions and Payments P� Far No. mpt on Cede of Pay Earned Week Hours Worked Eath Day. I MO I FmInside reman !{; $.qd B.00I I I I i 4.00 20.05 5956 All I Fed FICA -State SDI ' Other Total 1,282.2G 17065 Protect protects Tex MocSecj Tax Ded Bad l "Rlher J 1,180.80 1.90S.2F 18&0e 145.75 O.00 289,21 62302 .1 Union H 6 W Pension Vacation Training Other Cash 203.4C 285.00 45.00 70.0C 94,72 Xher -Any ocher deduot ons, contributions arWor payments whe"r or not included or requireG by prevailing CERTIF164T1QN AST be completed wage determinations must be separately hated. Use extra sheets if necessary. Date 09/3021 1, Fran Jarvis Chief Financial Officer (Name of signatory party) (Title) do hereby certify under penalty of perjury: (1) That I pay or supervise payment of the persons employed by San Joaquin Electric Inc on the (Contractor or Subcontractor) Keller Heavenly PRV ; that during the payroll period commencing on the (Building or Work) 22nd day of September, 2021, and ending the 28th day of September 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 San Joaquin Electric 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 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: FICA, Medicare, Federal Withholding Taxes, Labor Mgmt Hourly, Vacation % (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 duty registered in a bona fide appren- ticeship program registered with a State apprenticeship agency recognized by the Bureau ofAppren- ticeship 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 X 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 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) REMARKS: EXPLANATION l� NAME AND TITLE SIGNATU j Fran Jarvis Chief inancialOfficer E WILLFUL FALSIFICATION OF ANY OF THOUWNt/S 'MAYS ACT' E CONTRACTOR OR 1 U6CONTRACTOR TO CML OR CRIMINAL SECTION 10e1 OF TntE 15 AND SECTION 231 OF 31 OF THE UNITED STATES CODE. 09/30/2021 02:20:20 PM Agency: South Tahoe Public Utility ❑is Contractor Address: 2342 Teepee Drive Stockton, CA 95213 License: CSLB 410103 PWCR- 1000002857 Insurance Nvrn: Notes: Employee Edmun Santos 1345 Cahi Circle Gardnerrille, NV 89460 .ass: Inside Wireman Foreman Exem p- 0 San Joaquin Electric Inc California Dept of Industrial Relations Payroll Report Week Ending: 0912312021 21032 - Keller Heavenly PRV Project ID: 371032 Email: fran@sanjoaquinelec#ric,com FEI N: 942753280 I Hours Worked Wed Thu Fri Sat Sun Man Tue Week Type 09122 09123 09124 09126 09126 09127 09128 Total Rafe Regular: 8.00, 8. 4.00 20.00 59.5 Overtime: 89.31 Doublebme: 119.0 Cash Fringe: Travel/Subs: Total Jab Pay: Page 1 of 1 a-------- This Job > All Jabs Pay Employer Paid Deductions Pay 1,190.80 VacfHol: Fed: 188.06 Cross: 1,905.28 H & W: 158,40 FICA: 145.76 Deduct: 333.81 Pension: 210.00 State: 0.00 Net: 1,282.26 Training: 25.00 SDllt_ooal: 0.00 Checkfl: 17065 Other_ 49.72 FundlAdmin: 1,190.80 Total: Z 12 Dues: savings: Other. 0.00 Total, 333,81 eCPR Online Confirmation 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: SAN JOAQUIN ELECTRIC, INC. Contractor Address: 2342 TEEPEE DRIVE STOCKTON CA 95205 Awarding Body: SOUTH TAHOE PUBLIC UTILITY DISTRICT Project ID: 371032 Contract With: CREEKSIDE ELECTRICAL CONTRACTORS, INC. Week Ending Date: 2021-09-28 Payroll Number: 1 Amendment Number: 0 1 employee payroll record(s) processed Your Transaction ID is: 12221797 Print this Paae View your submission r -� Submit another set of payroll records 09-21 Keller Water Storage Improvements Project 109-21 Kellar VVater Storage Improvements Project U.S. Department of Labor PAYROLL. ' No Wage and Hour Division (For Contractor's Optional Use; See Instructions at www,dol,govlwhdlformsfwh347instr.htmj F, Persons respond are not requrnad to to the collection of informaliDn unless it displays a currently valid OM8 I?Qr1fR91 number. Rev.. Dec. 1i)py e'� 'mr Hour 1)itiirion NAME OF CONTRACTOR © OR SUBCONTRACTOR [ l!ADDRESS: OMB No.: 1235.0009' Creekside Etectdcal Contractors, Inc. j 3059 Airport Rd., Carson city, NV, 89708 Iiii I Exr�mz: 7131I2024 PAYROLL NO. FOR WEEK ENDING: PROJECT AND LOGATtQN: PROJECT OR CONTRACT NO. 8 9f2912021 09-21 Yeller Water Storage Improvements Project, CA I09-21 Keller Water Storage Improvements Praje4 ftr ar tat (a) DRY AND DATE 053 (6] 4+] t67 f2l Thu I Fd I Sat I Sun I Mon I Tue Wed D�uCnous HAt+tl: AfaP INOMDVRL IDENTIFYING NUMER `a 89YC3 os2A osrzs osa6 oE'27 a9ns 09r29 VATHl TOTAL r AID FOR [a.E LAST NuRDlGlrsor:socta4 wows TOTAL ROTE OF PAY GROSS AMOUNT FICA HOWiNG STATE TA) LOCAL OTHER OEPVf} WEEK S@GLIFJTY NVMaL-7tlOFWORl9ER rf C-ASSIFICATtON HOURS WORKED EACH DAY HOURS EARNED TRY TANS MFrC 3H ELEcrmc "INSIDE VVIMM w s 0.00 0.00 0.00 0.00 0.00 $.00 8.00 10.00 $59,541$0,00 5952 Stl 1 0 0.00 0.00 0.00 0.00 0.00 0:00 0.00 0.00 $0.001$0.00 97.99 108.00 61.23 0.00 160.76 447.98 832.82 t] 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 $0.001$0.00 $1,190.80 While complet nr. of FDrm Wi4.347 is Optional, it A manciftry for covered contraclom and subcontraclom perfomting w&k on Federallyfmanced or assisted constructlon contracts to respond to the information conecton contained in 29 CT.R. §§ 3.3. 5.Staj. The Copeland Act (44 U.S.C. § 3145) con!rddors and suhmnlracters performing work en Fe&�mlly financed or assisted conswctinn contracts to'lumish wcsldy a statement with reapaulto the wages paid each employee during the preceding weelt.' U.S. Dopartrnent of Labor (t791-) mgulationsat 29 C.F.R. § 5.5(a](3][li; revere conhantors to submit weekly a copy of all payrolls to the Federal agency contracting for or F.nancirg the oonstruclion project, accompanied by a s49ned'Statement of Compliance' indicating that the payrolls are correct and complete and dr t tjch laborer or mecha nie has been paid rent less than the pmpg!" DRYM-l3aCOn prerailiiG xaga rate for the work parfomwd. DOL and federal cont aclirog agencies receiving this information review the Information to determine that employees have received lega4y regrind wages and ircga benelRs. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection. Inolud[ng time for ravI& ng instructions, searching a fWing data sources, gathering and makdsining rho data noeded, and comptang and -AInc thv collection of information, IFyoU havo any Comments regarding these estimates Malty other aspect of this Collation, including suggestions for reducing this burden, send them to the Administrator. Waga and Hour Division, US. Department of Labor. Roam 53502, 200 Avenue, W.W. Washington, D.C.20210 Page 5 of 2 09-21 Keller Water Storage Improvements Project / 09-21 Keller Water Storage Improvements Project Date: 10/4/2021 (b) WHERE FRINGE BENEFITS ARE PAID IN CASH Jennifer Andrews President E]— 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) 09-21 Keller Water Storage Improvements Project EXCEPTION (CRAFT) EXPLANATION (Building or Work) ; that during the payroll period commencing on the 23 day of September , 2021 and ending the 29 day of September , 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 Start. 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 (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 ®--- 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. REMARKS: NAME AND TITLE SIGNATURE Jennifer Andrews, President THE WILLFUL FALSIFICATION OF ANY OF TAIE�ABOVE STTEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 3729 OF TITLE 31 OF THE UNITED STATES CODE. Page 2 of 2 10/4121, 10:29 AM eCPR Form Application eCPR Online Confirmation 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: 2021-09-29 Payroll Number: 8 Amendment Number: 0 1 employee payroll record(s) processed Your Transaction ID is: 12240535 Print this Page View your submissionMobe Submit another set of payroll records https://efiling.dir.ca.gov/eCPR/pages/eCPROnlineFormPreFill.jsp 1/1 California PUBLIC WORKS PAYROLL REPORTING FORM 1 1 Department of Page of Name of Contractor. Industrial Relations San Joaquin Electric Inc Contractor License No: 410103 Address: 2342 Teepee Drive PO Box 30068 or Subcontractor Specialty License No: Stockton, CA95213 1 Payroll No: 2 ( For Week Ending: 10/05/21 Self -insured Certificate No: Project or Contract No: Workers` Comp. Policy No: Project and Location: 21032-Keller Heavenly PRV (4) Day (5) (6) (1) (2) W I TH I F( S I S M T I 9) Name, Address and No of (3) I Date Total Hourly (7) (8) I Net WCh gs eck 1 Social Security Number W/H Work Earn {09/29(09/30(f0/01�10/02�10103(10/04�10f05� Hours Rate GrossAmountDeductions, Eamed Contributions and Payments Paid For No. Week of Employee Exempt Classification Code of Pay Hours Worked Each Day _ Performed This All - Fed. F1CA State SDI `Other Ded Total Ded No Work Proiect Proiects Tax (SocSec) Tax H & W Pension Vacation Training Other Cash i - - - - CERTiFI ATiON M ST be completed * ither-Any other deductions, contributions and/or payments whether or not included or regr fired by prevailing F.-A-1-131 (N-2-80) wage determinations must be separately listed. Use extra sheets if necessary. Date 10/07/21 1, Fran Jarvis Chief Financial Officer (Name of signatory party) (Title) do hereby certify under penalty of perjury: (1) That I pay or supervise payment of the persons employed by San Joaquin Electric Inc on the (Contractor or Subcontractor) Keller Heavenly PRV : that during the payroll period commencing on the (Building or Work) 291h day of September, 2021, and ending the 5th day of October 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 San Joaquin Electric Inc from the full (Contractor or Subcontractor) weeklywages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, otherthan permissible deductions as defined in Regulations, Part 3 (29 CFR SubtRte A), Issued by the Secretary of Labor under the Copeland Act, as amended (48 Slat. 948, 63 Stat. 108, 72 Stat 967; 76 Stat 357; 40 U.S.C. 3145), and described 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 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 duty registered in a bona fide appren- ticeship program registered with a State apprenticeship agency recognized by the Bureau of Appren- ticeship 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 tabor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS X In addition to fhe 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 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) REMARKS: EXPLANATION NQ441EAIS6T(TCE SIGSJATU / Fran Jarvis Chief Financial Officer �' ((�CHEw1LLFUL FALSIF{CATION OF ANY OF THEASO M 'ITSt �UBCONiRACTOR TO CIVIL OR CRIMINAL PROSE N. SEE SE SUaJ -CT NTRACTOR OR N 1001 OFTITLE 18 AND SECTION 2310E TI.E 31 OF THE UNITED STATES CODE. 10/07/2021 02:27:55 PM Agency: South Tahoe Public Utility Dis Contractor Address: 2342 Teepee Drive Stockton, CA 95213 License: CSLB 410103 PWCR: 1000002857 Insurance Num: Notes: San Joaquin Electric Inc California Dept of Industrial Relations Payroll Report Week Ending: 10/05/2021 21032 - Keller Heavenly PRV Project ID: 371032 Email: fran@sanjoaquinelectric.com FEIN: 942753280 Hours Worked ----> Wed Thu Fri Sat Sun Mon Tue Week Employee Type 09/29 09/30 10101 10102 10103 10/04 10/05 Total Rate Regular: l Overtime: Doubletime:l SSN: Cash Fringe: Class: Travel/Subs: Exemp: Total Job Pay: <------ This Job --------> Pay Employer Paid Vac/Hol: H&W: Pension: Training: Other. Total: Page 1 of 1 <__- --- - All Jobs ---- ------ —> Deductions Pay Fed: Gross: FICA: Deduct: State: Net: SDI/Local: Check#. Fund/Admin: Dues: Savings: Other. Total: eCPR Online Confirmation 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. Statement of non-performance created... Contractor Name: SAN JOAQUIN ELECTRIC, INC. Contractor Address: 2342 TEEPEE DRIVE STOCKTON CA 95205 Awarding Body: SOUTH TAHOE PUBLIC UTILITY DISTRICT Project ID: 371032 Contract With: CREEKSIDE ELECTRICAL CONTRACTORS, INC. Week Ending Date: 2021-10-05 Payroll Number: 2 Amendment Number: 0 0 employee payroll record(s) processed Your Transaction ID is: 12279356 Print this Paoe View your submission — Adobe Submit another set of payroll records Public VVorlts Certified Payroll Reporting Form ertlflcat/on under penalty of perfury: "1, FRAN JARVIS, the undersigned, am the CFO (position in business) with the authority to act for and on behalf of SAN JOAQUIN ELECTRIC INC (name of business and/or contractor), certify under penalty of perjury that the records or copies thereof submitted and consisting of certified payroll records for the week ending 2021-10-05 are the originals or true, full, and correct copies of the originals which depict the payroll record(s) of the actual disbursements by way of cash, check, or whatever form to the individual or individuals named. I certify this on 2021-10-07 " ontractor Name: SAN JOAQUIN ELECTRIC INC Contractor PWCR: 1000002857 License Type: CSLB License Number 410103 ddress: 2342TEEPEE DRIVE, STOCKTON, CA95213 FEIN: 942753280 Contractor Email: FRAN@SANJOAQUINELECTRIC.COM isurance Number. warding Body: SOUTH TAHOE PUBLIC UTILITY DISTRICT DIR Project ID: 371032 Project Name: KELLER-HEAVENLY WATER SYSTEM IMPROVEMENTS PROJECT, PHASE 1 REBID ontract With: CREEKSIDE ELECTRICAL CONTRACTORS, County: EL DORADO Address: HEAVENLY VALLEY NEIGHBORHOOD, SOUTH LAKE TAHOE, CA 96150 INC. ayroll Number: 2- 0 For Week Ending: 10/05/2021 U Is this a'Statement of Non -Performance?' Public works Certified Payroll Reporting Form 10/07/2021 - Page 1 09-21 Keller Water Storage Improvements Project 109-21 Keller Water Storage ImpraV e r•, en is Project U.S. Department of Labor PAYROLL Wage and Hour Division (For Contractor`s Optional Use; See Instructions at www.dol.govtwhdfforrnstwh347instr,html) WA�v Persons are nni required to respond to the collectibn ofinformaflan unless it displeye a! currently valid OMB confrol number. Rev. Dec. 2008 M45 H13 L-S. % a;;o an:l Hour 1)i%i,ion NAME OF CONTRACTOR OR SUBCONTRACTOR © ADDRESS: ! OMB No.: 1235-0008 CreeksWe Electrical Contractors, Inc. I3059 Pdrport Rd., Carson City, NV, 69706 ! Expires: 7/3112024 PAYROLL NO. FOR WEEK ENDING: I PROJECT AND LOCATION. PROJECT OR CONTRACT NO. Ij 9 101W021 I09 21 Ke:ler Water Storage IrTipmvernents Project, CA I 09-21 Kesler Water Storage Improvements Project nt (2) r3l J 4j DAY AN9 DATE {si [a1 m (A) tgj Thu Fri Sat Sun Mon Tue Wad OEDUCnONS NAME ANtrltiorvhouA4 S 0mo I lam low I 101➢a I 7tll0a I 1"s I iuJ KETWA� IoLurimmm mumseR PA6 FOR WITH- TOTAL LAST FOUR Dp O OF SC ERI- t FFC TffTRL Ft1'FE OF PRY GROSS NFDlltiT "C.°- F1GYAX STATE TA} L�'t UIT-IETt OEDIFG yrEEr( SF_Ci1W1YNVMaER] OF WORKER � ClAC57FTCATIOH t[0ltR4 WO^nld_tr EACH BAY r+OUP.s Ewv-vEn 1'^x T� TrtrN3 �H EtEcrRtcusntrlustht vwREMArt 5 8.00 0.00 0.00 0.00 0.00 0.00 0.00 B.00 $59.54130.00 $475,32 T O 0.00 0.00 0.00 0.00 0,00 0.00 0.00 0.00 $0.00 MAD 3B.73 19.00 7.54 0.00 72.30 137_57 3",75 D 0.00 0.00 0.OD 0.00 0.00 0.00 0.00 0.00 $U.UU1$0.00 $475.32 While compJaon or Form WH-34T is Qpponal, IL Is mandatory for covered contractors and sub=ftctors perfonning work on Federal"nanced or assisted conouction contracts to respond to the irdonnation wileetion contained in 29 C.F.R. §§ 3.3, 5 5(2y The Copatand Act (40 Ll.S.C. 3 3145) �?n+ractors and sut)coniradvrs perfomang work on Federally fmanced orasslsted construction evntracts Wfumish weeldy a statement with respaet to the wages paid each ernplcyee during the promdhg weak" U.S. Depanawnt of labor (DOL) regutabons at 29 C.F.R g 5,5(a),3+flij require contractors to subm tweeldy a copy of al payrolls to the Federal agency contracting for or financing the construction prajaM aemmpanfed by a signed'Stalemard of Compliance' mdicating fhatthe paytons are tomcat and aompteke and that e❑ch laborer or mechanic has been paid not less than the proper Davis-ftoor prevaaing wage rate forthe work pwforavd. DOL and federal contracting agencies recalving this Information review the Information to d6b9Tmino that amployeas have received legally required wages zad fringe bcneritt, Pubflc Burden Stalemenl We eaflaoW thal is vdir lake an average of 55 adnules 19 complete this collection, Including time for reviewing insiructlons, searching eAsting data sources, gathering and maintaining the data needed. and completing and reviewing the caAeetien of fnfornWGon. IF you have any comments regarding these esllmates or any other aspect of this collection, including suggestions for reducing this burden, send thorn to the Administrator, Wage and hour Drdslon, U.S. Department of Labor. Room S3502, 2130 CcnsbV!Dn Avenue, N-W_ Washington, D.C.2A21D Page 9 of 2 09-21 Keller Water Storage Improvements Project / 09-21 Keller Water Storage Improvements Project Date: 10/8/2021 (b) WHERE FRINGE BENEFITS ARE PAID IN CASH I Jennifer Andrews President F-1- 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) 09-21 Keller Water Storage Improvements Project EXCEPTION (CRAFT) EXPLANATION (Building or Work) ; that during the payroll period commencing on the 30 day of September , 2021 and ending the 06 day of October , 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 Start. 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 (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 QX — 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. REMARKS: NAME AND TITLE (SIGNATURE Jennifer Andrews, President 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 3729 OF TITLE 31 OF THE UNITED STATES CODE. Page 2 of 2 10/8/21, 10:16 AM eCPR Form Application eCPR Online Confirmation 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: 2021-10-06 Payroll Number: 9 Amendment Number: 0 1 employee payroll record(s) processed Your Transaction ID is: 12285669 Print this Page t, View your submissionAdobe Submit another set of payroll records https:Hefiling.dir,ca.gov/eCPR/pages/eCPROnlineFormPreFill.jsp 1/1