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Contractor:
Creekside Electrical Contractors, Inc.
For week beginning on: 10/21/2021
For week ending on: 10/2712021
Payroll Number: 12
Project:
09-21 Keller Water Storage Improvements Project
09-21 Keller Water Storage Improvements Project
10/28/202'1
1, 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: 10/27/202,1.
I herein certify under penalty of perjury that all of the above is true and correct as submitted.
Jenhifer AndreWs,, President
10/28/21, 10:56 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.
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: 2021-10-27
Payroll Number: 12
Amendment Number: 0
0 employee payroll record(s) processed
Your Transaction ID is: 12445987
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https://efiling.dir.ca.gov/eCPR/pages/eCPROnlineFormPreFill.jsp 1/1
California
PUBLIC WORKS PAYROLL REPORTING FORM
De artmentof
Page 1 of 1
1
1 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, CA 85213
Payroll No: 5
For Week Ending: 10/26/21
Self -Insured Certificate No:
Project or Contract No:
Ssll
Workers' Comp. Policy No:
Project and Location: 21032-Keller Heavenly PRV
(4) Day
(5) I (6)
(1)
(2)
W TH_I F I S ( S M - T
-
- - -
-.._
(9)
Name, Address and
No of
(3)
Date
Total
Hourly (7)
O Net Wgs Check
Social Security Number
WM
Work
Earn
10/2010/2110/22110/23`10/24110/251f0/26
Hours
Rate GrossAmount
Pay Earned
Deductions, Contributions and Payments
Paid For No.
Week
of Employee
Exempt
classification
Code
Hours Worked Each Day
of
1
No Work Performed
This All
Proiect Projects
Fed. FICA State
Tax_ jSocSecl Tax
SDI ' Other Total
_ Ded Ded
1
H & W Pension Vacation Training Other Cash
" Other -Any other deductions, contributions and(or payments whether or not included ur required by prevailing
CERTIFICATION MUST be completed 1
wage determine Eons must be separately fisted.
Use extra sheets if necessary.
F>ma-1_tai tn<w zsol
Date 10/27/21
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
1. Fran Jarvis Chief Financial Officer
(Name of signatory party) (t itte) 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 or perjury: 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.
(1) That 1 pay or supervise payment of the persons employed by
(c) EXCEPTIONS
San Joaquin Electric Inc on the
(Contractor or Subcontractor)
_ Keller Heavenly PP.V ; that during the payroll period commencing on the EXCEPTION (CRAFT EXPLANATION
(Building or Work)
20th day of October , 2021, and ending the 261h day of October 2021
all persons employed an 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 behaff of said
San Joaquin Electric Inc from the full
(Contractor or Subcontractor)
weekly wages earned by any person and thatno 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 Sublille A), issued by the Secretary of Labor under the Copeland Act, as amended (48
Slat- M, 63 Stai, 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 REMARKS:
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 ride 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 orwill be made to appropriate programs for the benefit of such
employees, except as noted In Section 4(c) below.
' NAME AND TITLE SIGNAT
FmnJarvis
Chief Financial Officer
ii�rNE WILLFVLFALSIFICATION OF ANY OF iHEASOVE
ISVaCONrRACTOR TO CIVIL OR CRIMINAL PROSE
t
ENENi5 SUBJECT m.E CDNTFiACTOR OR
N. SEE SE rON 1001OFTITLE11IAIOSECTION271oF
I ITLE 31 OF THE UNITED STATES CODE
Agency- South Tahoe Public Utility Dis
Contractor Address: 2342 Teepee Drive Stockton, CA95213
License: CSLB 410103
PWCR: 1000002857 Insurance Num:
Notes:
California Dept of Industrial Relations Payroll Report
Week Ending: 10126/2021
21032 - Keller Heavenly PRV Project ID: 371032
Email: fran@sanjoaquine(ectric.com
FEIN: 942753280
Hours Worked >
Wed Thu Fri Sat Sun Mon Tue Week
Employee Type 10/2010121101221012310/2410/2510126 Total Rate
-- �.w
Regular. -
Overtime: I- �r �rlO mtj
Doubletime:
SSN: Cash Fringe:
Class: Travel/Subs:
Exemp: Total Job Pay:
<----- This Job - - - -->
Pay Employer Paid
Vac/HoC
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 payro(I 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: 2021-10-26
Payroll Number: 5
Amendment Number: 0
0 employee payroll record(s) processed
Your Transaction ID is: 12430326
Print this Paae
View your submission Abe.
Submit another set of payroll records
Public Works Certified Payroll Reporting Form
ertlrlcatlon 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 2021-10-26 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 2021-10-27."
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. I
ayroll Number: 5- 0 For Week Ending: 10/26/2021 U is this a'Statement of Non -Performance?'
public taorks certified Payroll Reporting Form 10/27/2021 - Page 1