HomeMy WebLinkAbout25.3 Contractor's Payroll
State ~f California Payro I I
Department of Transportation For Contractor's Optional Use: Instructions. Form HC-347 Instructions
Payroll Form HC-347
Name of Contractor ~ Canon Coating Company Address P.O.BoX 399, Norco, CA 91760
Subcontractor
Payroll No. 1 For Week Ending- 05/25/96 Project and Location Foothill & Locust - Fontana [ Contract No,
OT Day and Date (5) (6) Gross amount Deductions (Based on Gross Amount Earned-All Projects)
and Social Security ~ Work
Number of Classification ST 19 [ 21 Hours of Pay ~is Ad~ Fed, FICA State SDI
Project Projects Tax (Soc. Tax
employee Houm Worked each Day Sec)
Paul Arzate 5 Striper O
6298 Jones Avenue 19.93
Rivemide, CA 92504 41.79 321.39 4.66 2.58
556-25-9149 S
1.5 1.5 27.86
GregopJ A. Swiney I Trainee, Step 1 O
19402 Diplomat Ave. 12.06
Corona, CA 91719 ~ 24.50 194.60 14.26 2.82 ,74 1.56 5.50 157.66 3158
548-71-4460 S ~ !
~ 1.5 [ 1.5 16.33
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Statement of Compliance
State of California
Department of Transportation
Form HC-348 Date June 4, 1996
I ,Patsy Marguet, Bookkeeper, do hereby certify under penalty of perjury:
(1) That I pay or supervise the payment of the persons employed by Canon Coating Company on the _Foothill & Locust-Fontana , that
dudng the payroll commencing on the __19th__day of __May ,1996 and ending the ._25th day of__May. ,1996, all persons
employed on said project have been paid their full weekly wages earned, that no rebates have been or will be make either directly or indirectly to
or on behalf of said Canon Coating Company from the full 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 described below:
Federal & State Taxes. Voluntary Deductions. (
(2) That any payrolls otherwise under this contract required to be submitted for the above pedod 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 or she performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, QR PROGRAMS
I'1 in addition to the basic houdy wage rates paid to each laborer or mechanic listed in the above referenced payroll,
payments of fringe 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 4(c) below.
(b) ~RE FRINGE BENEFITS ARE PAID IN CASH
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 basic beudy 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
Remarks:
NAME AND TITLE: Patsy Marguet, Bookkeeper - ~ ,~
On federally-funded projects, permissible deductions are defined in Regulation, Part 3(29 CFR Subtit bor , as amended (48 Stat. 948 63 Stat.
108; 72 Star. 967;76 Star. 357;40 U.S.C.276c)
Also, the willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution(see Section 1001 of Title 18 and Section 231 of Title 31 of the
United States Code).
Stat~ of CalifOrnia Payroll
Department of Transportation For Contractor's Optional Use: Instructions. Form HC-347 Instructions
Payroll Form HC-347
Name of Contractor ["'[ Canon Coating Company Address P.O.BOx 399, Norco, CA 91760
Subcontractor
Payroll No. I For Week Ending- 4~20~96 Project and Location Locust and Foothill I Contract No.
OT Day and Date (5) (6) Gross amount Deductions (Based on Gross Amount Earned-All Projects) Net
No. ol Earned Wages Check
and Social Secudty ~'~ Work
This All Fed. FICA State SDI VAC Other Total Paid for
"="P Classification ST ]4 Hours of Pay Project Prcjects (SOc. Tax Deduc week
Number of I I Tax
employee HouPs Worked each Day Sec) tion
Paul Arzate 4 Group 1, Traffic O
6298 Jones Avenue Delineating 29.07
Riverside, CA 92504 Device 51.14 468.84 22.37 6.80 .53 3.75 3.00 403.32 3070
556-25-9149 Applicator S
-' 2.0 2.0 25.57
Ben Newton 4 Tminee, Step 1 O
9519 Msple Ave. i 34-42
Hesperia, CA 92345 S ~ 28.56 555.t7 46.28 8.05 13.58 4.45 7.90 440.49 3080
573-55-4218 2.0 2.0 14.28
Jeff Marguet I Trainee, Step 1 O ~
4239 Woodward Ave. 13.17
Norco, CA 91760 S 28.56 212.50 16.95 3.08 1.09 1.70 5.50 171.01 ~ 3068
567-23-4675 2.0 2.0 14.28
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Statement of Compliance
State of California
Department of Transportation
Form HC-348 Date. April 25, 1996
I ,Patsy Marguet. Bookkeeper, do hereby certify under penalty of perjury:
(1) That I pay or supervise the payment of the persons employed by Canon Coating Company on the __Locust & Foothill , that
during the payroll commencing on the __14th__day of April ,1996 and ending the __20th_day of Apdl ,1996, all persons
employed on said project have been paid their full weekly wages earned, that no rebates have been or will be make either directly or indirectly to
or on behalf of said Canon Coating Company from the full 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 described below:
Federal & State Taxes. Voluntary Deductions.
(2) That any payrolls otherwise under this contract required to be submitted for the above pedod 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 or she performed.
(3) That any'apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
r"3 In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll,
payments of fdnge 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 4(c) below.
(b) ~ERE FRINGE BENEFITS ARE PAID IN CASH
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 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
Remark:
NAME AND TITLE: Patsy Marguet, Bookkeeper SIGNATUR~ ' ·
On federally-funded projects, permissible deductions are defined in Regulation, Part 3(29 CFR Subtitle A), issued by the Se~La~ct, as amended (48 Stat. 948 63 Stat.
108; 72 Star. 967;76 Star.357;40 U.S.C.276c)
Also, the willful falsification of any of the above statements may subject the contractor or subcontractor to civil or cdminal prosecution(see Section 1001 of Title 18 and Section 231 of Title 31 of the
United States Code).
ELECTRICAL CONTRACTING, INC
DATE: ,~//~,~/~/~
S.J. Burkhart
6157 Marlatt
Mira Loma, CA 91752
PROJECT DESCRIPTION: Loops Replace Existing - Fontana
JOB # S742 YOUR JOB/SUBCONTRACT #
We are hereby transmitting the following document(s):
[/}(] CERTIFIED PAYROLL:
[~] Week Ending: ~)'/o~//~6 Payroll # / ] ] No Employees
Payroll # [ [ No Employees
] ] Period Ending: Payroll # ] ] No Employees
] [ Statement of Compliance for each week or period.
] ] Fringe Benefit Statement
] [ EEO Report for Month Ending:
] [ Safety Meeting Record Dated:
[ ] Other Items/Comments:
Thank you,
Moore Electrical Contracting, Inc.
463 N. SMITH AVENUE · CORONA, CA 91720-6905 · (909) 371-4202 ° FAX (909) 371-4296 ° LICENSE NO. 610382
RUN DATEr .05/29/96 ~ Moore Electrical contracting, Inc. '- PAGE: Z1
SY~ DATE: 05/22/96 463 N. Smith Avenue TIME: 07:19 A~
Corona, California 91720
JOB NUMBER: S762-009
JOB NAME: Fontaria Loops
JOB LOCATION: Fontana Loops
CERTIFIED PAYROLL REPORT
CONTRACT NO: FOR THE WEEK ENDING: 05/22/96
PAYROLL NO:
EMPLOYEE NAME EMPLOYEE WORK CL4~S WORK CLA~S TOTAL PAY E/B GROSS EARNINGS DEDUCTIONE
ADDRE89 NUMBER CODE DESCRIPTION HOURS RATE RATE TOTAL DEDUCTIONS ~ EMPLOYER
SOCIAL SECURITY NUMBER NET PAY CONTRIBUTIONS
Heaps Jr, Dennis J 07-0000419 PORE000 Poreman $29.88 CHECKS 024461 EXEMPTS: 4 M FED W/H 250.97
7612 Malachite Ave THU PRI SAT SUN MON TUE WED TOTAL PAY F/B GR/JOB: 89.64 PICA 96.33
Rancho Cucamonga,Ca 91730 05/16 05/17 05/18 05/19 05/20 05/21 05/22 HOURS RATE RATS GR/TOT: iS53.76 MEDICARE 22,53
O .00 .0O .00 .00 .00 .00 .00 .00 .00/ .00 DED/TOT: 610,70 CA SDI 12.43
SEN: 551-67-8447 S .00 3.00 .00 .00 .00 .00 .00 3.00 29.88/ .60 NET/TOT: 943.06 CA W/H 68.74
PACE: C CAUCASIAN SEX: M Train LA 4.32
VAC Elect 155.38
Simpllcio,Paul 07-0000422 TECH001 Tech I $20.14 CHECKS 0244,53 EXEMPTS: 2 ~ FED W/H 126.91
13301 Kelowna St THU FRI EAT SUN MON TUE WED TOTAL PAY F/B GR/JOB: 60.42 PICA 49.95
Azlet~,C~ 91331 05/16 05/17 05/18 05/19 05/20 05/21 05/22 HOURS RATE RATE GR/TOT: 805.60 MEDICARE 11.68
O .00 .00 .00 .00 .00 .00 .00 .00 .00/ .00 DED/TOT: 316.18 CA EDI 6.44
SEN: 549-67-1186 S .00 3.00 .00 .00 .00 ,00 ,00 3,00 20.14/ .00 NET/TOT: 489.42 CA W/N 37.04
RACE: H HISPANIC SEX: M Train LA 3.60
VAC Elect 80.56
Marilyn J. McGowan / PayroB Officer
the Yontans Loops~ that during the payroZZ period commencing on 05/16/1996 a/~d ending on 05/22/1996
all persons employed on said project have been paid the lull weekly wages earned, that no rebates have been or will be made either
(2) That any paymils otherwise under this contract required to he submitted for the above period are correct and complete;
that the wage rate 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 apprenticeship program registered
with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or
if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States
(4) That: (a} W~BRB FRINGB BBN~PITS ARB PAID TO APPROVBD PLANS, FUNDS, OR PROGRAMS
IX] -- In addition to the basic hourly wage rates paid to each l~borer or mechanic listed in the above referenced payroll,
payments of fringe benefits ae listed in the contract have been or will be made to appropriate programs for the benefit of such
employees, except as noted in Section 4 (c) below.
(b) WHBRB FRINGB BBNBFITS ARB PAID IN CASH
[ } -- Bach 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 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) BXCBPTIONS (CRA[T) ~XPLANATION CASH/LIBU AMT/HOUR TO PLAN
** NO BXCSPTIONS TO RBPORT FOR THIS JOB **
n n j McGowan
ELECTRICAL CONTRACiNG, INC.
S.J. Burkhart
6157 Marlart
Mira Loma, CA 91752
PROJECT DESCRIPTION: Lc~>ps Replace Existing - Fontana
aOB ~ S742 YOUR aOB/SUBCONTRACT #
We are hereby transmitting the following document(s):
])(] CERTIFIED PAYROLL:
[ ] No Employees
Payroll # [ ] No Employees
] ] Period Ending: Payroll # ] ] No Employees
] [ Statement of Compliance for each week or period.
] ] Fringe Benefit Statement
] ] EEO Report for Month Ending:
[ ] Safety Meeting Record Dated:
] ] Other Items/Comments:
Thank you,
Moore Electrical Contracting, Inc.
463 N. SMITH AVENUE · CORONA, CA 91720-6905 · (909) 371-4202 ° FAX (909) 371-.4296 ° LICENSE NO. 610382
RUN DATE: 07/02/96 ~ Moore Electrical contracting, Inc. ~ PAGE: 23
SYS DATE: 07/03/96 463 N. smith Avenue TIME: 03:16 PM
Corona, California 91720
JOB N~TMBER: S742-000
JOB NAME: Fontana Loops
JOB LOCATION: Fontana Loops
CERTIFIED PAYROLL REPORT
CONTRACT NO: FOR THE WEEK ENDING: 06/30/96
PAYROLL NO:
EMPLOYEE NAME EMPLOYEE WORK CLA~$ WORK CLASS TOTAL PAY F/B GROSS EARNINGS DEDUCTIONS
ADDRESS NUMBER CODE DESCRIPTION HOURS RATE ~TE TOTkL DEDUCTIONS AND EMPLOYER
SOCIAL SECURITY NUMBER NET PAY CONTRIBUTIONS
Perez,David 07-0000711 L3~BUON4 Lab/Sawman $20.35 CHECK# 024960 EXEMPTS: S FICA 50.47
2503 Cottonwood Trail NON TUE WED THU FRI SAT SUN TOTAL PAY P/B GR/JOB: 325.60 MEDICARE 11.80
Chino Hills,Ca 91709 06/24 06/25 06/26 06/27 06/28 06/29 06/30 HOLTRS RATE RATE GR/TOT: 814.00 CA SDI 5.51
O .00 .00 .00 .00.00 .00 .00 .00 .00/ .00 DED/TOT: 296.13 Credit Un 50.00
SSN: 547-61-4824 S .00 .00 .00 8.00 8.00 .00 .00 15.00 20.35/ .00 NET/TOT: 517.87 Gam~iehme 100.00
RACE: H HISPANIC SEX: M Laborer 69.60
LiEe/Rmti 7.75
RUN DATE: 07/02/96 ~' Moore Electrical Contractingl Inc, ~ PAGE: 24
SYS DATE: 07/03/96 STATEMENT OF COMPLIANCE TIME: 12:00 AM
DATE: JUNE 30, 1996
Marilyn J. McGowan / Payroll ~
I, , do hereby state:
name of signatory party title of signatory party
(1} That I pay or supervise the paplent of the persons employed by Moore Electrical Contracting, Inc. on
the Pottans Loops; that during the payroll period commencing on 06/24/1996 and ending on 06/30/1996
all persons employed on said project h~ve 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 Moore Electrical Contracting, Inc. from the full weekly wages earned by any
persons and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than
the pel~aissible deductions as defined in Regulations, Part 3 (29 CFR subtitle A), issued by the Secretary of Labor under the
Copeland Act, as amended (48 9tat. 948, 63 Stat. 108, 72 Star. 967; 76 Star. 357; 40 U.S.C. 276c), and described below:
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;
that the wage rate for laborers or mechanics contained therein are not less than the applicable waqe rates contained in any wage
determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic confo~ with
the work he performed.
(3) That any apprentices employed in the above period are duly reEistered in a bona fide spprentlceshlp pzogram registered
with a State apprenticeship aEency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or
if no such recognlzed agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States
Department of Labor.
(4) That: (a) WHERE FRINGE BENEFITS ANE PAID TO APPROVED PLANS, FUNDS, OB PROGRAMS
[X] -- In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll,
payments of fringe 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 41c) below.
(b} WHERE FRINGE BENEFITS ARE PAID IN CASH
[ ] -- 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 basic hourly wage rate plus the amount of the required fringe beneEits as listed in the
contract, except as noted in Section 4(c) below.
(c) EXCEPTIONS (CR~FT) EXPLANATION CASH/LIEU AMT/HOUR TO PLAN
** NO EXCEPTIONS TO REPORT FOR THIS JOB **
---~-~--~-,,^ (F~ C~m~ractm's Ol~tional Use: See hstmctions. FORM }1C-~7 tts'G-ucGons) ~'~(,, ~ 7 ~ j ~/~,4"~,t=
~?~"~"~ ORS~eC~a~CZ~ AyALA BORING INC. 10150 Poplar Avenue, Fa~tana, CA 92335
Ange~ Cervantes S Laborer
18361 Banyan St. 3 Group 1
mia~to, c~ 92376
~552-9~ 0734
Eladio Cervantes M Operator
222~4Yucca Ave. 8 Group 4
Rialto, CA 92376
Ismael Cervantes M Laborer
12554 Ma9nolia Ave. 5 Group 1
ehino, ca 91710
603-18-9072
157 B '"M'" St. 2 Group 1
Colton, CA 92324
~'TATI~ OF CALJFORNJA STATEMENT OF COMPLIANCE
DEPARTMENT OF TI~ANEI;~)RTATION
L Sue C'o. 11en Bookkeeper do bereby c~rti[y under Fnalty of perjury:
t9 ~ and ending the ~ day of ~ .19 ~, all ~r~ns emplnyed on said proiect have ~en paid their full w.kly
PayroZ~ Taxes, ~ed~ca~ ;nanfence, Uniform ~xpense, DenCa~ ZnDa~ance,
~aqe Carn~shmen~ ann F=~nqe
(2I That any payrolls otherwise under this costract required to be submitted for the above Fried are correct and complete; that the wage rat~s for
latxlrers or mechanie~ contained therein are ant lea than ~he applicable wage: rata contained in any wage determination incorporated into the contract; that
tile classi flearich set forth therein for each laborer or mechanic conform with the work hc or she performed.
t3) That arty apprentices employed in the above period are duly registered in a bona fide apprenticeship progrant registered with a State apprenticeship
agency.
(41 That:
in) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS. FUNDS, OR PROGRAMS
~ln addition Io the basic hourly wage rates paid to each labt~rer or mechanic listed in the adore referenocH pa roll, payments of fringe
benefits as listed in the contract have been of will Ix! made to appropriate programs far the benefit of such emp~'~yees, except ~ noted in
beetion 4(c) below,
(hi WIlERE FRINGE BENEFITS ABE PAID IN CASH
] Each Lahor~!r or mechanic listed in the above referenced parcel] has h~en paid as Idicated on the payre an amoun no e~ h~.n be sum
nf the appbcable basic hourly wage rate plus the atomrot of ihe r~:quired fringe bone:fits as listed in the c~,~tract, ~xcept as noted in Section
, ~.Z,~ ~ ~ j~ ..... '~ "" ""' ''~ t,,~ ";~ ' '~:'~~
~".~,V;:,,'...~.,.~ ;~2~/.,,,~""~ c" ' ....................""" I, ,., ...... ] .....................
State 6f"Califomia Payroll
Department of Transportation For Contractor's Optional Use: Instructions. Form HC-347 Instructions
Payroll Form HC-347
Name of Contractor I""'1 Canon Coating Company Address P.O.Box 399, Norco, CA 91760
Subcontractor ~'1
Payroll No. 1 For Week Ending- 4/20/96 Project and Location Locust and Foothill j Contract No.
OT Day and Date (5) (6) Gross amount Deductions (Based on Gros= nount Earned-All Projects) Net
and Social Security "~ Work or S Total Rate This ~J~ Fed. FICA State SDI VAC Other ToW Paid for
~=~ Classification ST 14 Hours of Pay Project Tax (Soc. Tax Deduc week
Number of
~yee Hours Worked each Day 8ec) tion
Paul Arzate 4 Group 1, Traffic O
6298 Jones Avenue Delineating 29.07
Riverside, CA 92504 Device 51.14 468.84 22.37 6.80 .53 3.75 3.00 403.32 3070
556-25-9149 Applicator
-' 2.0 2.0 ,25.57
Ben Newton 4 I Trainee, Step 1 O
9519 Msple Ave. ! 34.42
Hesperia, CA 92345 S i 28.56 555.17 46.28 8.05 13.58 4.45 i 7.90 440.49 3080
i
Jeff Marguet 1 Trainee, Step 1 O
4239 Woodward Ave. 13.17
Norco, CA 91760 S 28.56 212.50 16.95 3.08 1.09 1.70 5.50 171.01 3068
567-234675 2.0 2.0 14.28
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Statement of Compliance
State of California
Department of Transportation
Form HC-348 Date,_Aprii 25, 1996
I ,Patsy Marguet, Bookkeeper, do hereby certify under penalty of perjury:
(1) That I pay or supervise the payment of the persons employed by Canon Coating Company on the __Locust & Foothill , that
dudng the payroll commencing on the __14th._day of Apdl ,1996 and ending the __20th_day of__Apdl ,1996, all persons
employed on said project have been paid their full weekly wages earned, that no rebates have been or will be make either directly or indirectly to
or on behalf of said Canon Coating Company from the full 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 described below: Federal & State Taxes. Voluntary Deductions.
(2) That any payrolls otherwise under this contract required to be submitted for the above period 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 or she performed.
(3) That any'apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS. FUNDS. OR PROGRAMS
['~ in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll,
payments of fringe 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 4(c) below.
RE FRINGE BENEFITS ARE PAID IN CASH
(b) ~ 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 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
{]1 EXCEPTION(CRAFT) EXPLANATION
Remark:
NAME AND TITLE: Patsy Margue, t, Bookkeeper SIGNATUR~ ·
On federally-funded projects, permissible deductions are defined in Regulation, PaCE 3(29 CFR Subtitle A). issued by the Se~La~ct. as amended (48 Star. 948 63 Stat.
108; 72 Star. 967;76 Stat. 357;40 U.S.C.276c)
Also, the willful falsification of any of the above statements may subject the contractor or subcontractor to civil or cdmiaal prosecution(see Section 1001 of Title 18 and Section 231 of T'Cde 31 of the
United States Code).
"pAyROLL (FOR CO~&TRACTOR'S OPTIOHAL USE|
~-.
_
._
· O ~; }~ (a) I'HERE FRINGE BENEFITS ARE PAID
~ pSla ~ ~J we~y wai~ e~med, ~st ~o ~[es have ~ or ~ll ~ ma~e eider di~y ~r 4 (c) below,
FAYROLL (FOR C~TRACTOR'$ OPTIONAL USE)
~-03'qL ~z ~ " ~z-~'
&~ ~ R~ s3~
~ ~'1~-~'~, '~(~4~-~-;~-~, (a) W~ERE FRINGE BEh'EF[T$ ARE PAJD TO
- ~c~J l~ L , ~ ~ ~my~l, M ~t not le~ ~
~:t du~l ~ p~wl) pe~od ~m~c~Z on ~e_ ~q~d~ of ~*: ~ ' ' ' Each employ~ stdjn The a~ve
~a~i ~d~ of ~ 19~, ~l pe~n, e~Floyed ~ "ieFroject ~.ve 4 (c) below.
State of California Payroll
DeparUnent of Transportation For Contractor's Optional Use: Instructions. Form HC-347 Instructions
Payroll Form HC-347
Name of Contractor ~ Canon Coating Company Address P.O.Box 399, Norco, CA 91760
Subcontractor i'~
Payrott No. 1 For Week Ending- 4/20/96 Project and Location Locust and Foothill I Contract No.
OT Day and Date (5) (6) Gross amount Deductions (Based on Gross Amount Earned-All Projects) Net
Ne. of Earned Wages Check
and Social Security '"~ Work
This All Fed. I FICA State SDI VAC Other ~)~1u Paid for I No.
'=~P Classification ST 14 18 Hours of Pay Project Tax I
Number of Projects (SOC, Tax c week
employee ] Hours Worked each Day Sec)3 00 fjon
t . Arzate i 4 Group 1, Traffic 0
6298 Jones Avenue Delineating 29.07
Riverside, CA 92504 Device 51.14 468.84 , 22.37 6.80 .53 3.75 . 403.32 3070
556-25-9149 Applicetor S
2.0 2.0 25.57 I i
Ben Newton i 4 !, Step 1 O
9519 Msple Ave. i i I 34.42
Hespeda, CA 92345 ~ S 28.56 i 555.17 46.28 8.05 13.58 4.45 7.90 440.49 3080
573-55-4218 I I 2 0 2.O 14.28
Jeff Marguet I TraineE Step 1 O
4239 Woodward Ave. 13.17
Norco, CA 91760 S 28.56 212.50 16.95 3.08 1.09 1.70 171.01 3068
567-23-4675 2.0 2.0 14.28
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Statement of Compliance
State of California
Department of Transportation
Form HC-348 Date._Apdl 25, 1996
I ,Patsy Marguet, Bookkeeper, do hereby certify under penalty of perjury:
(1) That I pay or supervise the payment of the persons employed by Canon Coating Company on the __Locust & Foothill , that
during the payroll commencing on the __14th._day of April ,1996 and ending the __20th_day of._Apdl ,1996, all persons
employed on said project have been paid their full weekly wages earned, that no rebates have been or will be make either directly or indirectly to
or on behalf of said Canon Coating Company from the full 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 described below:
Federal & State Taxes. Voluntary Deductions.
(2) That any payrolls otherwise under this contract required to be submitted for the above period 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 or she performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State
apprenticeship agency.
(4) That:
(a) VVHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
~1 In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll,
payments of fringe 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 4(c) below.
RE FRINGE BENEFITS ARE PAID IN CASH
(b) ~ 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 basic houdy 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
Remarks:
NAME AND TITLE: Patsy Marguet, Bookkeeper SIGNATUR~ -
On L-~clerally-fundecl projects, permissible deductions are defined in Regulation, Part 3(29 CFR Subtitle A), issued by the Se~La~ct, as amended (48 Star, 948 63 Star.
108; 72 Star. 967;76 Stat.357;40 U.S.C.276c)
Also, the willful falsffication of any of the above statements may subject the contractor or subContractor to civil or criminal prosecution(see Section 1001 of Title 18 and Section 231 of Title 31 of the
United States Code).
SOCIAL SECURITy NUMBER ~ CLA~FICKTIGN ST OURS
Angel ~ervantes S ~abh~er o
18361 Banyan St- 3 Group 1
rialto, CA 92376 s
32-97-0734 i
Eladlo Cervantes M Operator o
2224 yucca Ave. 8 Group 4
563-b5-39Oz
Ismael Cervantes M Operator o
12554 Magnolia 5 Group 4
Chine, CA 91710 s
Ismael Cervantes M Laborer o
12554 Magnolia A~eenue 5 Group l
Luis Perez S Laborer o /
157 S "M" Street 2 Group 1
eelton, CA 92324 s ~ ~ ~ ~ '~ ~D
~erardo Calderon M Laborer o
12036 Cherrywood Dr. ~ Group 1
{o~tana, CA 92337 3 s
0u6-42-6399
AguEtin Perez M Labboer o
157 E "M" St. 6 Group 1
Colton, CA 92324 s q ~ fl~?
..,. ,~/~ ..
Aya~a Borin Inc.
Wage Garnishment and Fringe BEnefits.
EXCEPTION (CRAFT) EXPLANATION
.~_.=-~7~.,~,1~ ~m~0m~cm~ AYALA BORING INC. ~ Poplar Avenue
· Fo~tana, CA 92335
Dean A ala S Laborer o
10855 ~erra Vista Pky. 1 Groupl
~smael Cervantes M Operator
12554 Magnolia A~e. 5 Group 4
Chino, CA 91710 , 9 ~ /~ ~1 ~ I'~ 7b
bUj-l~-gO72
157 S "M" Street 2 Group 1
· ~t_ ~ ~'~ (s) i~KERE FRINGE BENEFITS ARE pAID TO APPRO'~ED PLUS. ~ OR P~S
(1) ~ I ~ W q~e h p~meet of ~e pe~l employed ~ ~ made to ~p~dmte p~lr~s Eor ~e ~dil of luc~ mp~oyeew, ezapt n ~td h ~