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.j fO~RACTOR'S WEEKLY PAYROLL STATEMENTOF COMPLIANCE Date \~L \~t ~a~ Payroll No. 4 Gross Amount ~ \ I ~ ~'7 , 0 q , Pavroll Manager do hereby state: (TITLE) I, K~,uI\1ETH u:.. HAJ E..R... (NAME OF SIGNATORY PARTY) (J) That I payor supervise the payment of the persons employed by Carl Bolander & Sons Co. on the RdSEU \ u....;E Ac.,T~ J 1 'N CEU1ER- (CONTRACTOR OR SUBCONTRACTOR) (CONTRACT NO., BUILDING OR WORK, AND LOCATION). that during the payroll period commencing on the .:sQ. day of A);]D ,~(J~ and ending the ~ day of ~,".oo all persons employed on said projects 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 Carl Bolander & Sons Co from the ~ONTRACTORORSUBCONTRACTO~ full weekly wages earned by any person and that no deductions have been made or will be made, either directly or indirectly from the full weekly wages earned by any person, other than pennissible deductions, as defmed in the 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. 276c), and described below: Social Security: Federal Withholding & State WithholdinlJ Taxes Insurance: Advances (2) That any payrolls otherwise under this contract required to be submitted for the above are correct and complete; that wage rates for laborers or mechanics contained therein are not less than the minimum or applicable wage rates contained in any wage detennination incorporated into the contract; that the classifications therein set forth for each laborer or mechanic confonn with the work he perfonned; and that all laborers and mechanics shown on such payroll have been paid for all hours of work beyond ejght in a single day or 40 in the workweek at a rate not less than time and one-half the straight-time hourly wage rate therein set forth. (3) That any apprentices employed in the above period are duly regjstered in a bona fide apprenticeship program regjstered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or ifno such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United State 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 offiinge 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 (c.) below. (b.) WHERE FRINGE BENEFITS ARE PAID IN CASH - Each Laborer or mechanic listed in the above reference payroll has been paid as indicated on the payron, 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) EXPLANATION ~~ J~ 8 . 180NYA A. MACGAREN-BRIERI ' . I NOTARY PUBLIC - MINNESOTA . My Comm. Expires Jan. 31, 2005 . . 4 (Payroll Manager) ''J..1Y1 f) COO Sworn to before me this~ day of Di. . l~~ (SEAL) . ~ U1'iYlncJ:jJ;vf\ - 61w