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~\OkCI'OR'S WEEKLY PAYROLL STA TEMENTOF COMPLIANCE Date l \ ~ Q~(} Payroll No. .3 Gross Amou~ ~3 rz I G 5 I, K~NA)ETH J-E HI\,) E.~ , Pavroll Manager do hereby state: (NAME OF SIGNATORY PARTY) (TITLE) (1) That I payor supervise the payment of the persons employed by Carl Bolander & Sons Co. on the RoSE.u \ LL~ AGT'lHTY CENT~~ (CONTRACTOR OR SUBCONTRACTOR) (CONTRACT NO.. BUILDING OR WORK. AND LOCA TIPt"l. \ .. h that during the payroll period commencing on the. l~ day of ~,:iOq~ and ending the ~S day of IWU ,...29 all persons employed on said projects have been paid th~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 (CONTRACTOR OR SUBCONTRACTOR) 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 permissible deductions, as defined 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 Securi~: Federal Withholding & State Withholdin~ Taxes Insurance: Advances (2) That any payrolls othelWise 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 determination incorporated into the contract; that the classifications therein set forth for each laborer or mechanic conform with the work he performed; and that all laborers and mechanics shown on such payroll have been paid for all hours of work beyond eight 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 registered in a bona fide apprenticeship program registered 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) 111 at: . (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 fiinge 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 payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount afthe required fringe benefits as listed in the contract, except as noted in Section 4 (c.) below. (c.) EXCEPTIONS EXCEPTION CRAFT) EXPLANA TION . II I :TONYA A. MACGAREN-BRIER i ~ NOTARY PUBLIC - MINNESOTA I"" My Comm. ExpIres Jan. 31. 2005 .'^VN....r....v:......-.~~.....'..~'^.......,..NN. Sworn to before me this i 5th day of OD . IP 2fiXJ (SEAL) *Uf C1 irLt1ttJa11l1- 6J~