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pf_03243
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Last modified
7/17/2007 1:10:43 PM
Creation date
12/9/2004 6:58:20 AM
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<br />, CONTRACTOR'S WEEKLY PAYROLL STATEMENT OF COMPLIANCE <br /> <br />Date .~ ~)~ I .. Payroll No. 5 <br />, ~ <br />Gross Amount , '1 ~ . ~ 5 <br />, Pavroll Manager do hereby state: <br />(TITLE) <br /> <br />I, <br /> <br />K~,vNETH J....EHIUE.~ <br />(NAME OF SIGNATORY PARTY) <br /> <br />(I) That I payor supervisej\the paYme~Ofthe persons employed by Carl Bolander & Sons Co. on the <br />\\ r~ \\ lIt t C (CONTRACTOR OR SUBCONTRACTOR) <br />~E\j) ~ ~ C,;"t'iU) ~ ; <br />(CONTRACT NO., BUILD OR WORK, AND LOCATI~ <br />that during the payroll period commencing on the ~ day of .AN ,~t and ending the ~ day of TAN ,.-J.J all <br />persons employed on said projects have been paid the full weekly wages earned, that no rebates have been or will be made either directly <br />or indirectly to or on behalf of said Carl Bolander & Sons Co. from the <br />(CONTRACTOR OR SUBCONTRACTOR) <br />full weekly wages earned by any person and that no deductions have been made or will be made, either directly or indirectly from the <br />full weekly wages earned by any person, other than pennissible deductions, as defined in the Regulations, Part 3 (29 CFR Subtitle A), <br />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. <br />276c), and described below: <br />Social Security: Federal Withholding & State Withholding Taxes <br /> <br />Insurance: Advances <br /> <br />(2) That any payrolls otherwise under this contract required to be submitted for the above are correct and complete; that wage rates <br />for laborers or mechanics contained therein are not less than the minimum or applicable wage rates contained in any wage detennination <br />incorporated into the contract; that the classifications therein set forth for each laborer or mechanic confonn with the work he perfonned; <br />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 <br />workweek at a rate not less than time and one-half the straight-time hourly wage rate therein set forth. <br />(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with <br />a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or ifno such <br />recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United State Department of Labor. <br />(4) That: . <br />(a.) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS <br /> <br />_X_ <br /> <br />- In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, <br />payments offringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit <br />of such employees, except as noted in Section (c.) below. <br /> <br />(b.) WHERE FRINGE BENEFITS ARE PAID IN CASH <br /> <br />- Each Laborer or mechanic listed in the above reference payroll has been paid as indicated on the payroll, an <br />amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits <br />as listed in the contract, except as noted in <br />Section 4 (c.) below. <br /> <br />(c.) EXCEPTIONS <br />I EXCEPTION (CRAFT) I EXPLANATION I <br /> \2~~ iL <br /> (Payroll Manager) <br /> MARILYN J. KUKACKA <br /> NOTARY PUBLIC - MINNESOTA Sworn to before me this~ day of te..b . t9-...a..!XJ I <br /> My CommissIon expires Jan. 31, 2005 <br />(SEAL) Y2Il~"1 ?=I(~~ <br /> <br />
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