20211027110520110M-111filMN:'
Contractor:
Creekside Electrical Contractors, Inc.
For week beginning on: 10/14/2021
For week ending on: 10/20/2021
Payroll Number: 11
Project:
09-21 Keller Water Storage Improvements Project
09-21 Keller Water Storage Improvements Project
10/26/2021
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: 10/20/2021.
I herein certify under penalty of perjury that all of the above is true and correct as submitted.
Jen6if r Andrew , resident
10/26/21, 11:55 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: 2021-10-20
Payroll Number: 11
Amendment Number: 0
0 employee payroll record(s) processed
Your Transaction ID is: 12424055
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https://efiling.dir.ca.gov/eCPR/pages/eCPROnlineFormPreFill.jsp 1/1
Name. Address and
Social Security Number
of Employee
Fom, M7 `31 iNnvi 7-ee)
I California
Deppartment of
I indusUiai Relatlons
PUBLIC WORKS PAYROLL REPORTING FORM
I Name of Contractor. San Joaquin Electric Inc C0ntraetni License No: 410103
or Subcontractor. Specialty License No:
Payroll No: 4 For Week Ending: 10/19/21 1 Self -Insured Cartificate No:
(2)
No of
W/Ft
Fxemptl
ii Workers' Comp. Policy No:
(4) Day I (5) (6)—J
W{ TH } F y S I S I M) T
(3) Date Total Hourly (T)
Work " 10/1310/14 1D/1510/i6�i0/tTjt0/18)10/19j Hnurs Rate Gross Amount
Classification Code of Pay Earned
H W deed Each Da
Page 1 of 1
Address: 2342Teepee Drive PO Box 30065
Stockton, CA 95213 r
Project or Contract No:
I Project and Location: 21032-Keller Heavenly PRV i
i
s) j
(8) Net Wgs Check
Deductions, Contributions and Payments Paid For ! No,
ours o
- -- hh This JAII Fed. FICA State SDI ' Other
No Work Performed �i ProtecL_ Pro'ects Tax (Soc Sec) Tax Ded
- s
1' H & W Pension Vacation Training Other
' Hher- Any other deductions, contributions end/or payments whether or not included or required by prevailing
wage determinations must be separately listod. Use extra sheets if necessary.
Week
Total �
Ded
I
Cash
I! 1
CERTIFICATION MUST be completed
Date 10/20121
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
1, Fran Jarvis Chief Financial Officer
(Name of signatory party) (Title) 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
do hereby certify under penalty of perjury: basic hourly wage fate plus the amount of the required fringe benefits as listed
in the contract, except as noted in Section 4 (c) below.
(1) That I pay or supervise payment of the persons employed by
(c) EXCEPTIONS
San Joaquin Electric Inc on the
(Contractor or Subcontractor)
Keller Heavenly PAY _ ; that during the payroll period commencing on the EXCEPTION (CRAFT) EXPLANATION
(Building or Work)
13th day of October .2021. and ending the 19Ih 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)
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
SIaL 948. 63 Stat. 108, 72 Sint. 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 perfect
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 otAppren-
ticeship and Training, United Stales Department of Labor, Or if na such recognized agency exists in a
Stale, 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 houdy wage rates paid to each laborer or mechanic listed In
the above referenced payroll, payments of fringe benefits as Fisted in the contract
have been or Will be made to appropriate programs for the benefit of such
employees, exceptas noted in Section 4(c) below.
REMARKS.'
NAMEAND TITLE
SIGNAT11RC- I
Fran JerviFins
Chief Financial Officer
fHE WILLFULFALSIFICATION OFANY OF THEASO
ATEMENTS MAY ,9DBJECT THE CONTRACTOR OR
SUBCOMRACTOR TO CIVIL OR CRIMINAL. PRO
UTION. SEE SECTION 1001 of TITLE 1e AND SECTION 2Jf OF
rrrLE 31 OF THE UNITED STATES CODE
California Dept of Industrial Relations Payroll Report
Week Ending: 10/19/2021
Agency: South Tahoe Public Utility Dis 21032 - Keller Heavenly PRV Project ID: 371032
Contractor Address: 2342 Teepee Drive Stockton, CA95213 Email: fran@sanjoaquinelectric.com
License: CSLB 410103 FEIN: 942753280
PWCR: 1000002857 Insurance Num:
Notes:
<------------ Hours Worked >
Wed Thu Fri Sat Sun Mon Tue Week <— This Job ----- ->
Employee Type 10113 10/14 10/15 10116 10/17 10/18 10/19 Total Rate Pay Employer Paid
Re ular. _�'_-._�m.,_-_' Vac/HoL
Overtime: I ' R d.,,. QiT �Q C)C9 - — H & W:
Doubletme:) Pension:
SSN: Cash Fringe: Training:
Class: Travel/Subs: Other.
Exemp: Total Job Pay: Total:
Ail Jobs >
Deductions
`Pay
Fed:
Gross:
FICA:
Deduct
State:
Net:
SDULocal:
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: 2021-10-19
Payroll Number: 4
Amendment Number: 0
0 employee payroll record(s) processed
Your Transaction ID is: 12375197
Print this Paae
View your submission --- e
Submit another set of payroll records
Public VVorl(s Certified Payroll Reporting Form
artlflcatlon under penalty of perjury.
"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 2021-10-19 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 2021-10-20."
ontractor Name: SAN JOAQUIN ELECTRIC INC Contractor PWCR: 1000002857 License Type: CSLB License Number 410103
ddress: 2342 TEEPEE DRIVE, STOCKTON, CA 95213 Fr -IN: 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, 4- 0 For Week Ending: 10/19/2021 U Is this a 'Statement of Non -Performance?'
public works Certified Payroll Reporting Form 10/20/2021 - Page 1