Statement of Compliance - Professional Pipe Services - 2016-03-14 'i WK#
Statement of Compliance
I,Mike Wayne,HR/Payroll Manager,do hereby state: (1)That I pay or supervise the payment of the persons employed by
Hoffman Southwest Corporation d.b.a.Professional Pipe Services(Pro Pipe)on the Costa Mesa Sanitary District -CCTV
Project#RFP 02-15:thattduring the payroll� period.er � ® , ����
commencing on the /I day of J ,. 6 and ending the IP° day of_dA f 42x16 all persons
employed on said project 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 Hoffman Southwest Corporation d.b.a.Professional Pipe Services(Pro Pipe)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 defined in Regulation,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:
Mandatory withholding and elected employee benefit contributions.
(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 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 recognized 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 ARE PAID TO APPROVED PLANS,FUNDS,OR PROGRAMS
EIln 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 the employees,except as noted in Section 4c below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
❑x 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 4c below.
(c) EXCEPTIONS(CRAFT)
NONE
Remarks: CS=Child Support,KLoan=401K Loan,EEAR=Employee A/R
I,Mike Wayne,the undersigned,am the HR/Payroll Manager with the authority to act for and on behalf of Hoffman
Southwest Corporation d.b.a.Professional Pipe Services(Pro Pipe),certify under the penalty of perjury that the
records or copies thereof submitted and consisting of 6?-- pages are the originals or true,full,and correct
copies of the originals which depict the payroll record(s)of the actual disbursements by way of cash,check,or
whatever form to the individual or individuals named.
Certified by:
Signed: M. ayne,HR/Payroll Manager
Date: 3
Name of Contractor_or XX_Subcontractor Hoffman Southwest Corp.dba Professional Pipe Services(Pro-Pipe) 'Address: 23311 Madero,Mission V
If Subcontractor,name of Prime Contractor: I Costa Mesa Sanita District I Workers Comp-Zurich 0179545-00rCalifomia State Contractor No: 761395 Public Works Contractor Reg#10000001
Payroll No. 1 For Week Endin. 3/20/2016 Project Name/Location CCTV Ins•ection Project/Contract No.
eye•sale Individual Project Cash Earnings this s^Uctions
Name No.of 3/14 3/15 3/16 3/17 3/18 3/19 3/20 Rate of Pay Value of Non- Paned _
ExemP Work Classification M T W T F S S Total Hours (Cash Fringe Benefit Cash Fringe Total Combined Gross Earnings this FICA end
Social Security Notions on Project• Earning_s) Brkdown Benefits Rale on Project Period FIT Medicare Tax SIT SDI Other
HIS/Wed 0.00
Marco Antonio Sanchez Debora DT 0.00 55.02 Var✓Skk 0.00 55.02
S1 Apprentice Per.54:'"''''-' 229.16
OT - 0.22 0.22 41.270 1.011.01510n0,en 0.00 41.270
XXX-XX-5166 RG _ 8.00 8.00 27.51 Tow 0.00 27.51 580.03 59.92 44.37 12.56 5.22
HIth/Wed 2.14 Den 1(
Nader Zahreddine DT 0.00 81.68 yob 0.00 84.47 Med 131
M6 Apprentice Per.2 - 2,031.26 401K 121
OT 0.02 _ ion 0.35 0.37 0.10 0.35 1.19 65.260 Penso.65 68.050
XXX-XX-6910 RG 8.00 8.00_ 8.00 8.00 8.00 40.00 48.84 Torr 2.m 51.63 2,031.26 151.28 143.90 48.84 16.93
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Completed by/ , I Date:
Reviewed by, v7�`� 111". _ Date: 3124111,