20211015150652887Name, Address and
Social Security Number
of Employee
F—A-1-131 (N-2-83)
California
Department of
I Industrial Relations
PUBLIC WORKS PAYROLL REPORTING FORM
4 Name of Contractor. San Joaquin Electric Inc Contractor license No. 410103
i or Subcontractor. Specialty License No:
Payroll No: 3 I For Week Ending: 10/1221 I Setf4n3ured Certificate No-
No2of (3)
WIH Work
Exempt Classification
1 (4) Day (6)
Workers' Comp. Policy No: I (� ,
W I TH A F S S i M.. T. l --
Address: 2342 Teepee Drive
Stockton, CA 95213
Project or Contract No:
Project and Location:
Page 1 of 1
PO Box30068
21032-Keller Heavenly PRV
Total Hourly (7) (8)
Earn Date Hours Rate Gross Amount Deductions, Contributions and Payments
Cod-�10lD6�10lHours Worked
of Pay Earned
Hours Worked Each Day
No Work Performed Th-s All Fed. FICA state SDI "Other Total
Project Protects Tax (Soc Sec) Tax Ded_ Ded
H & W Pension Vacation Training I Other Cash
(9)
Net Wgs Check
Paid For No.
Week I
Other -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
wage determinations must be separately listed_ Use extra sheets if necessary.
Date 10/13/21
I. Fran Jarvis Chief Financial Officer
(Name of signatory party) (Tide)
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)
6th day of October , 2021, and ending the 12th day of October 2021 ,
all persons employed on said project have been paid the fug weeklywages 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 eamed 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:
(2) That any payrolls otherwise under this contract required to be submitted forthe 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 class fications 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 apprer-
gceship 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 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 taborer 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 houdywage 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
NAMEANO TITLE StGNATUR
Fran Jarvis
Chief Financial Officer
THE VALLFULFALSVICATION OFANY OF THEASOVE EMENTSfF�AAY SUOdECT THE CONTRACTOR OR
SUSCONTRACTORTO CIVIL OR CRIMINALPROSE ON. SEE SEf1TiONIMOFTITLEI8ANDSECTION231OF
TITLE 31 OF THE UNITED STATES CODE.
i�
Agency: South Tahoe Public Utility Dis
Contractor Address: 2342 Teepee Drive Stockton, CA 95213
License: CSLB 410103
PWCR: 1000002857 Insurance Num:
Notes:
California Dept of Industrial Relations Payroll Report
Week Ending: 10/12/2021
21032 - Keller Heavenly PRV Project ID: 371032
Email: fran@sanjoaquinelectric.com
FEIN: 942753280
<-___------- a Hours Worked
Wed Thu Fri Sat Sun Mon Tue Week
Employee Type 10106 10/07 10108 10/09 10110 10/11 10/12 Total Rate
Regular.,
Overtime: .,A.,,,
Doubletime:
SSN: Cash Fringe:
Class: Travel(Subs:
Exemp: Total Job Pay:
<-----This Job -
Pay Employer Paid
Vac/Hol:
H&W:
Pension:
Training:
Other:
Total:
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: 2021-10-12
Payroll Number: 3
Amendment Number: 0
0 employee payroll record(s) processed
Your Transaction ID is: 12317046
Print this Paoe
e �
View your submission Ad
Submit another set of payroll records
Public Works Certified Payroll Reporting Form
erdflcatlon under penalty of perjury:
"I, 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 2021-10-12 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 2021-10-13:'
ontractor Name: SAN JOAQUIN ELECTRIC INC Contractor PWCR: 1000002857 License Type: CSLB License Number 410103
ddress: 2342 TEEPEE DRIVE, STOCKTON, CA 95213 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.
ayroli Number: 3- 0 For Week Ending: 10112/2021 U Is this a 'Statement of Non -Performance?' 1
Public works certified Payroll Reporting Form 10/13/2021 - Page 1
10/15/2021
Contractor:
Creekside Electrical Contractors, Inc.
For week beginning on: 10/7/2021
For week ending on: 10/13/2021
Payroll Number: 10
Project:
09-21 Keller Water Storage Improvements Project
09-21 Keller Water Storage Improvements Project
CA
CERTIFICATION FOR NON -PERFORMING WEEH
I, Jennifer Andrews the undersigned, am the President with the authority to act for and on behalf of Creekside Electrical
Contractors, Inc.
certify under penalty of perjury that no work was performed for the week ending on: 10/13/2021.
I herein certify under penalty of perjury that all of the above is true and correct as submitted.
9t A
Je7f;r Andrews resident
1
10/15/21, 9:07 AM 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.
Statement of non-performance created...
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: 2021-10-13
Payroll Number: 10
Amendment Number: 0
0 employee payroll record(s) processed
Your Transaction ID is: 12341794
Print this Page
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View your submission
Submit another set of payroll records
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