20211117113012935FORTMMAMMMI MMMMMM
Contractor:
Creekside Electrical Contractors, Inc.
For week beginning on: 1114/2021
For week ending on, 11 /10/2021
Payroll Number: 14
Project:
09-21 Keller Water Storage Improvements Project
09-21 Keller Water Storage Improvements Project
'11/12/2021
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: 11/10/2021.
I herein certify under penalty of perjury that all of the above is true and correct as submitted.
J et 'tr 'Prsident
11/12121, 9:47 AM eCPR Form Appilcation
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: 2021-11-10
Payroll Number: 14
Amendment Number: 0
0 employee payroll record(s) processed
Your Transaction ID is: 12571266
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https:Hefiling.dir.ca.gov/eCPR/pages/eCPROnIineFormPreFilI.jsp 1/1
California
PUBLIC WORKS PAYROLL REPORTING FORM
De��ariment of
Page 1 of 1
I
tndusfrieI Relations
I Name of Contractor
San Joaquin Electric Inc
Contractor License No: 410103
Address: 2342 Teepee Drive PO Box 30069
or Subcontractor.
Specialty License No.
Stockton, CA 95213
l Payroll No: 7
For Week Ending: 11/09/21
Self -Insured Certificate No:
i Project or Contract No: E
Workers ' Comp. Policy No:
i Project and Location: 21032-Ketter Heavenly PRV
(4) Day I
('� (s) I
!
(1)
(2)
- .d W I TH I F--I -S I S -'--M -! T-•-----�g�--
Name. Address and
No of (3)
Date (
Total Hourly (7)
(8) Net Wgs Check
Social Security Number
Employee
W/H Work
E:.;:.
Hours Rate Gross Amount
Deductions. Contributions and Payments Paid For No.
of
Exempt Classification
Code{11/03IiT/04.It1Po5I11/06,ttl071110811/09
Hours Worked Each Day
of Pay Earned
Week
Performed ryry
adoWorkP
Imo,
-------_
I This All Fed,
._...T...— —ate
FICA Stale SDI 'Other Total
Tax Ded Ded
.. _.. i!
1 ProieU Projects Tax
,Loc Sec)
H & W
Pension Vacation Training Other Cash
' )ther-Any other deductions, contributions nndfor payments whetheror not included or required by prevailing CERTIFICATION MUST be completed
Fom, a-r_rar ;new z-sor
wage determinations must be separately listed. Use extra sheets it necessary.
Date 1110921
- - --- — (b) WHERE FRINGE BENEFITS ARE PAID IN CASH
1, Fran Jarvis Chief Financial Officer
(Name of signatory parry) (Tdle) 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 houdywage rate plus the amount of the required fringe benefits as listed
in the contract, except as noted in Section 4 (a) 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 PRV ; that during the payroll period commencing on the EXCEPTION (CRAFT) EXPLANATION
(Building or Work)
3rd day of November, 2021, and ending the 9lh day of November 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
Slat 948. 63 StaL 108. 72 SIaL 967; 76 StaL 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 duly 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
Slate, 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
I NAMEAND TITLE
Fran Jarvis
SIGNATIIR� J ,
niwage rates paid to each taborer or mechac listed in
X In addition to the basic hourlyFinn
— the above referenced offringe benefits as listed in the
Chief Financial Officer
+i f�
payroll, payments contract
have been or will be made to appropriate programs for the benefit of such
employees,
FE WILLFUL FALSIFICATION OF ANY OF THE ABOVE.$I
UeCONmACTOR TO
TATEMENTS MAySMECT THE CONTRACTOR OR
except as noted in Section 4(c) below.
CML OR CRIMINAL PROSEC"ON. SEE SECTION 1001 OF TITLE 19 AND SECTION 231 OF
TLE 31 OP THE UNITED STATES CODE ..� i
Agency: South Tahoe Public Utility Dis
Contractor Address: 2342 Teepee Drive Stockton, CA 95213
License: CSL6 410103
PWCR: 1000002857 Insurance Num:
Notes:
SSN:
Class:
Exem p:
California Dept of Industrial Relations Payroll Report
Week Ending: 11/09/2021
21032 - Keller Heavenly PRV Project ID: 371032
Email: fran@sanjoaquinelectdc.com
FEIN: 942753280
Hours Worked ----------->
Wed Thu Fri Sat Sun Mon Tue Week
Employee Type 1110311/0411/05 11/06 11107 11/08 11/09 Total Rate
Regular: - —
.-
Overtime:
Doublet��rI�___�- I
ime: _ � ��-' �u t
Cash Fringe:
Travel/Subs:
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:
Your payrolt submission request has been processed.
Please review the results of your submission. Should you have any questions please contact the eCPR unit at
pub]icworks@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: 2021-11-09
Payroll Number: 7
Amendment Number: 0
0 employee payroll record(s) processed
Your Transaction ID is: 12540765
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Public Vlforlcs Certitied Payroll Reporting Form
ertfflcation 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 2021-11-09 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 2021-11-09."
ontractor Name: SAN JOAQUIN ELECTRIC INC Contractor PWCR: 1000002857 License Type: CSLB License Number 410103
ddress: 2342TEEPEE DRIVE, STOCKTON, CA95212 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: 7- 0 For Week Ending: 11/09/2021 U is this a'Statement of Non -Performance?'
Public Works certified payroll Reporting Form 11/09/2021 - Page 1