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. ~ONTRACTOR'S WEEKLY PAYROLL STATEMENTOF COMPLIANCE Date \ ~ t .~J~~ Payroll No. 3 Gross Amount at. ~ \4'2> '1. ~ 5 I, K~,uN~H J,J:.. HI\J E.R... , Payroll Manager do hereby state: (NAME OF SIGNATORY PARTY) (TITLE) (I) That I payor supervise the payment of the persons employed by Carl Bolander & Sons Co. (CONTRACTOR OR SUBCONTRACTOR) on the Rc-sysv\ l.LE. Acr\U\TY C;E4\JTiSR- (CONTRACT NO.. BUILDING OR WORK. AND LOCA TIN) .. L- that during the payroll period commencing on the -13- day of cj U ,:toO~ and ending the ~ day of ~,..~ 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 (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 pennissible 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 Security: Federal Withholding & State Withholdine 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 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 Deparnnent of Labor, or ifno such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United State Deparnnent 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 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 of the required fringe benefits as listed in the contract, except as noted in Section 4 (c.) below. (c.) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION II i . . TONYA A. MACGAREN-BRlERI NOTARY PUBLlC- MINNESOTA My Comm. Expires Jan. 31, 2005 . ~~ Sworn to before me this 18 ih day of Gl..6 . ~ 21)(,:'0 (SEAL) ~ OJ fYLI1r;:Jtl/l1 n- 61LM