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Date 10-26-16 <br /> (b)WHERE FRINGE BENEFITS ARE PAID IN CASH <br /> I Stephanie McCollum Office Manager <br /> (Name of Signatory Party) (Title) ❑ — Each laborer or mechanic listed in the above referenced payroll has been paid, <br /> as indicated on the payroll,an amount not less than the sum of the applicable <br /> do hereby state: basic hourly wage rate plus the amount of the required fringe benefits as listed <br /> in the contract,except as noted in section 4(c)below. <br /> (1)That I pay or supervise the payment of the persons employed by <br /> McCollum's Excavating LLC (c)EXCEPTIONS <br /> on the <br /> (Contractor or Subcontractor) EXCEPTION(CRAFT) EXPLANATION <br /> London Mine ;that during the payroll period commencing on the <br /> (Building or Work) <br /> 15 day of October 2016 and ending the 21 day of October 2016 <br /> all persons employed on said project have been pald the f ull weekly wages earned, that no rebates have <br /> been or will be made either directly or indirectly to or on behalf of said <br /> McCollum's Excavating LLC <br /> from the full <br /> (Contractor or Subcontractor) <br /> weekly wages earned by any person and that no deductions have been made either directly or indirectly <br /> from the full wages earned by any person,other than permissible deductions as defined in Regulations,Part <br /> 3(29 C.F.R.Subtitle A),issued by the Secretary of Labor under the Copeland Act,as amended(48 Stat.948, <br /> 63 Stat.108,72 Stat.967;76 Stat.357;40 U.S.C.§3145),and described below: <br /> REMARKS- <br /> (2)That any payrolls otherwise under this contract required to be submitted for the above period are <br /> correct and complete;that the wage rates for laborers or mechanics contained therein are not less than the <br /> applicable wage rates contained in any wage determination incorporated into the contract;that the classificabons _ <br /> set forth therein for each laborer or mechanic conform with the work he performed. <br /> (3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship <br /> program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and <br /> Training,United States Department of Labor,or if no such recognized agency exists in a State,are registered <br /> with the Bureau of Apprenticeship and Training,United States Department of Labor. <br /> (4)That: <br /> (a)WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS,FUNDS,OR PROGRAMS NAME AND TITLE SIGNATURE <br /> Stephanie McCollum,Office Manager <br /> © — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in <br /> the above referenced payroll, payments of fringe benefits as listed in the contract THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR <br /> have been or will be made to appropriate programs for the benefit of such employees, SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE <br /> except as noted in section 4(c)below. 31 OF THE UNITED STATES CODE <br /> 4[ <br /> 4 <br /> f <br />