2019-09-29 thru 2021-05-09 Cert PayrollCANCaliramia PUBLIC WORKS PAYROLL REPORTING FORM
DLpwtr cnt of
Industrial Rclaliom
Page
i NAME OF CONTRACTOR: PWLC 11, INC. CONTRACTORS LICENSE NO.:855783 ADDRESs'3584
E LA CAMPANA WAY, PALM SPRINGS CA92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
I PAYROLL NO.: 1 FINAL FOR WEEK ENDING: 09/29/2019 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLO-Eisenhower at Sinaloa St
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.; WSD 5029463 PROJECT AND LOCATION:
(1)
(2) 1 (3)
M T W fT. 1 F 1 S I S
(7J
(S)
(9)
DATE
NET WOS
CHECK
NAME, ADDRESS AND
I
I WORK
TOTAL
HOURLY
RATE
GROSS AMOUNT
23 124 25 2 6 2 7 2 R 2 9
SOCIAL SECURITY NUMBER
y O CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
OF EMPLOYEE
c o (
W I
WEEK
_
z M
HOURS WORKED EACH DAY
3 I Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
610.07
27066
Margaro Castillo
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
&WRLF.
PENSION
68750 Ortega Rd
(Maintenance
Laborer
S
8
6
16
17.00
264.75
692.75
22.35
52.99
.41
6.93
0.00
0.00
0.00
Cathedral City CA 92234
1
I
TRAING.
FUND
DUES
TRAV
SUBS./
SAVINGS
OTHER"
TOTAL
DED C-
I
•5
25.50
ADMEN
TION.4
1
0
•5
0.00
0.00
0.00
0.00
0.00
0.00
0.00
1 (Landscape
THIS
ALL
FED,
FICA
STATF.
VAC/
HEALTH
573.61
27067
Pedro Reyes Dimas
I Maintenance
PROJECT
PROJECTS
TAX
(SOT, SEC)
TAX
SDI
HOLIDAY
& N'ELF.
PENSION
31-900 Avenida El Mundo
Laborer
S
8
8
8
24
16.00
420.00
676.0
336.83
51.70
6.90
6.76
0.00
0.00
0.00
Cathedral City CA 92234
1
TRAING,
FIND
DUES
TRAV/
SUBS.
SAVINGS
OTHER"
TOTAL
DED C-
I
1
5
1.5
24.00
AD MIN
TIONS
I
O
0.00
0.00
0.00
0.00
0.00
0.00
102.19
2 I Landscape
THIS
ALL
FED.
MCA
SE
HEALTH
509.05
27068
Ronaldo Grajeda Ortega
I Maintenance
PROJECT
PROJECTS
TAX
(SOT SEC.)
TAT
SDI
HOLIDAY
H'ELF
PENSION
31470 Avenida El Mundo
Laborer
g
B
8
8
4
26
13.00
412.75
578.50
19.00
44.26
.40
5.79
0.00
0.00
0.00
Cathedral City CA 92234
'
TRAIN..
FUND
DUES
SURB.9V/
SAVINGS
OTHEH�
TOTAL
DEDUC-
E
I
O
1
5
1
2.5
19.50
ADMEN
TION9
0.00
0.00
0.00
0.00
0.00
0.00
69.45
1 I Landscape
THIS
ALT,
FED.
FICA
STATE
VAC/
HEALTH
513.63
27069
Juan M Lepez
1 Maintenance
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
13146 Nilsen Ct
Laboroer
S
6
8
16
15.00
240.00
Beaumont CA 92223
1
I
600.00
29.23
45.91
5.23
6.00
0.00
0.00
0.00
TRAING.
FUND
DUES
TRAV/
SUBS.TION9
SAVINGS
OTHER-
AL
DEDUC-
I
ADMENTO
1
0
0.00
0.00
0.00
0.00
0.00
0.00
86.37
S=STRAIGHT TIME •o3 HER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be Completed
Form A-1-131(Nm 2-80) O=OVERTIME wage determinations must be separately listed, Use extra shect(s) ifnecessary (See reverie side)
SDI= STATF, DISABILITY INSURANCE
_■;� Cal�rnmi. PUBLIC WORKS PAYROLL REPORTING FORM
ri Depertrlent of
Jndu ad.1 ReloUom
Page
NAME OF CONTRACTOR: PWLC 11, INC. CONTRACTOR'S LICENSENO.: 855783 ADDRESS: 3584 E LA CAMPANA WAY, PALM SPRINGS CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
PAYROLLNO.:1 FINAL FOR WEEK ENDING: 09/29/2019 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ-Eisenhower at Sinaloa St
(4) DAY (S) (b) WORKERS' COMPENSATION POLICY NO.: 1/IISD 5029463 PROJECT AND LOCATION;
(1)
(2) 1 (3)
M T W 7FF S S
(7)
(tl)
(9)
DATETOTAL
NET WOS
PAID FOR
WEEK
CHECK
NO
NAME, ADDRL•SS AND
SOCIAL SECURITY NUMBER
OF EMPLOYEE
i 1 WORK
Do CLASSIFICATION
o o I
HOURS
HOURLY
RATE
OF PAY
GROSS AMOUNT
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
23 24 25 1 26 27 2E 29
MI
HOURS WORKED EACH DAY
Rafael M Vera
13040 Cactus
Desert Hot Springs CA 92240
2 1 Landscape
Maintenance
1 Laborer
I
I
S
8
6
8
4
28.00
14.00
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VAC/
HOLIDAY
HEALTH
& WELF.
PENSION
544.28
27070
444 .50
623.00
23.45
47.66
1.38
6.23
0.00
0.00
0.00
I
I
O
1
•5
1
2.50
21.00
TRAING.
FUND
ADMIN
DIMES
THAV
SUBS. UBS.1
SAVINGS
OTHER•
TOTAL
DOTAL
-
TIONS
0.00
0.00
0.00
0.00
0.00
0.00
78.72
j
TITTS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC.)
STATE.
TAX
SDI
VAG
HOLIDAY
HEALTH
& WELF.
PENSION
I
S
1
T
TRAING.
FUND
ADMIN
DUES
VI
SUBS.
SAVINGS
OTHER"
TOTAL
DEDUC-
TIONS
I
O
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
IS
STATE
TAX
SDI
VAG
HOLIDAY
HEALTH
&WELF.
PENSION
1
s
i
1
TRAfNG.
FUND
ADMIN
DUES
SI B9 I
SAVINGS
OTHER'
TOTAL DEDUC-
TIONS
1
O
1
1
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VAG
HOLIDAY
HEALTH
&WELF.
PENSION
I
S
1
TRAING.
FUND
ADMIN
DUES
TRAM
SUBS.
SAVINGS
OTHER'
TOTAL
DEDUC-
TIONS
1
T
o
S = STRAIGHT TIME -OTHER- Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Fuml A-1-131 (New 2-90) O = OVERTIME wage determinations must be separately listed. Use extra shect(s) if necessary (See reverse side)
SDI = STATE DISAHILI'rV INSURANCE
NDTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 Kristy South
(Name — print)
Controller
(Position in business)
PWLC II INC
the undersigned, am the
with the authority to act for and on behalf of
__ _ , certify under penalty of perjury
(Name of business and/or contractor) �S t ti a W G r cz
that the records or copies thereof submitted and consisting of Form A-1-131, 3 pages
(Description, number of 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.
Date: 1 0/04/201 9
Signature: lr "'
A public entity may require a stricter and/or more extensive form of certification.
CiRCulironlia PUBLIC WORKS PAYROLL REPORTING FORM
Dcpannenl of
lndustrinl Rclnlims
Page T _ of
NAME. OF CONTRACTOR; ONTRACTORS LICENSE NO.: ADDRESS'
PWLC II, INC.. 855783 3584 E La Campana Way, Palm Springs CA 92262
I Olt
SUBCONTRACTOR: SPECIALII Y LICENSE NO:
I PAYROLLNO.: 1 FINAL FOR WEEK ENDING: 10/13/2019 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
CCLQ 101 Tree Removal
(4) DAY (5) (C) NORKERS' COMPENSATION POLICY NO.: WSD 5029463 PROJECT AND LOCATION:
(U
(1) 1 (3)
M T W TH F S S
(7)
(S)
(9)
DATE,
NET WGS
CHECK
NAME, ADDRESS AND
1
� r WORK
TOTAL
OURLY
IIRATE
RATE
GROSS AMOUNT
07 O(J 1 09 1 10 11 12 13
SOCIAL SECURITY NUMBER
u O CLASSIFICATION
1
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
OF EMPLOYEE
o o
WEEK
4 W r
HOURS WORKED EACH DAY
4 ITree Maintenance
THIS
ALL
FED,
FICA
STATE
\'AC/
HEALT1
644.53
6036/60
Luna Gonzalez, Carlos
I Laborer
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SIN
HOI IDAY
& {\'FI F
PENSION
38
66145 7lh St
S
g
6
20.62
123.72
708.96
3.10
54.24
0.00
7.09
0.00
0.00
0.00
Desert Hot Springs CA 92240
t
I
TOTAL
r
TRAING.
FUND
DUES
SUBS.TRAY/
SAVINGS
OTHER"
1
AOMIN
TIONR
!
O
0.00
0.00
0.00
0.00
0.00
0.00
64.43
4 1 Tree Maintenance
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
183.77
27136
Chavez, Alejandro
I Laborer
PROJECT
PROJECTS
TAX
(SOC.SEC,)
TAX
SDI
HOLIDAY
WELF.
PENSION,
2103 Jacques Drive
6
6
26.92
161.55
215.40
11.16
16.48
1.84
2.15
0.00
0.00
0.00
Palm Springs CA 92262
1
S
r
TRAING.
FUND
DUES
5UAV/
SAVlN4'9
OTHER'
TOTAL
UEDUC-
1
ADMIN
THNS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
31.63
IS
THVA
ALL
CA
YTATTAXE
HEALTH
r
PROJECT
PROJECTS
TAX
(S CI SEC.)
SDI
HOLI AY
a ELF
PENSION'
I
S
I
1
TRAING.
DUES
TRAYr
SUBS.
SAVINGS
OTHER'
TOTAL.
llEDUC-
1
AFUNDDMIN
1'IONS
I
0
E
THIS
ALI,
FED.
FICA
STATE
VACI
HFAL'rH
r
PROIECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
6R'ELF.
PENSION
I
S
I
TAL
TRAING.
FUND
DUES
S ns.
SAVINGS
OTIIER•
nenuc-
ADMIN
THINS
I
0
S�SFRAIGHTrIMI: •(r1HI:E-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
N-A-1-131 (N-2-0e) On OVF:RTIMH wage deteralinulions must be separately listed. Use extol shect(S) Irneecssery (See reverse side)
SDI - STA'I I. DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Priivacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 Kristy South
(Name — print)
Controller
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLA 101 Certified Payroll, 2 pages
(Description, member of 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.
Date: 10/15/2019
Signature:
A public entity may require a stricter and/or more extensive form of certification.
ciRCulifemie PUBLIC WORKS PAYROLL REPORTING FORM
Dcpurt-It of
Industrial Retalions
Page
F NAME. OF CONTRACTOR: PWLC II, INC. CONTRACTOR'S LICENSE NO.: ADDRESS:
OR SUHCOM'RACTOR: SPECIALITY LICENSE NO: 855783 3584 E La Campane Way, Palm Springs CA 92262
1 PAYROLL NO.: 1 FINAL FOR WEEK ENDING: 10/13/2019 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ 105 Tree Trim
(4) DAY (5) (G) WORKERS' COMPENSATION POLICY NO.: WSD 5029463 PROJECT AND LOCATION:
(I)
(2) 1 (3)
M T W TH F' S S
(7)
(E)
(9)
NAME, ADDRESS AND
r
E WORK
TOTAL
HOURLY
RATE
GROSS AMOUNT
DATE
07 OR 09 10 11 12 13
SOCIAL SECURITY NUMBER
u c CLASSIFICATION
E
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
NFT WGS
PAID FOR
CHECK
NO
OF EMPLOYEE
WEEK
9i. GI r
HOURS WORKED EACH DAY
4 (Tree Maintenance
THIS
ALL
FED.
FICA
STATE
ClV,\
HEALTH
E4Z3
6036/60
Luna Gonzalez, Carlos
I Laborer
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
38
66145 7lh St
S
2
2
20.62
41.24
708.96
3.10
54.24
0.00
7.09
0.00
0.00
0,00
Desert Hot Spdngs CA 92240
I
1
TRAING.
FUND
DU S
su.V1
SAVINGS
OTHER'
TOTAL
DEDUC-
r
E
ADMIN
TIONA
E
0
I
IT
I
1
0.00
0.00
0.00
0.00
0.00
0.00
64.43
4 1 Tree Maintenance
THIS
ALL
FED.
FICA
STATE
VAC(
IIEAI.TH
183.77
27136
Chavez, Alejandro
(Laborer
PRO]L•CT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
2103Jacques Drive
S
2
2
26.92
53.88
215.40
11.16
16.48
1.84
2.15
0.00
0.00
0.00
Palm Springs CA 92262
i
I
TRAING.
FUND
DUES
SUBS.
SAVINGS
OTHER'
DEDUC-
1
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
31.63
r
'THIS
ALL
FED.
FICA
STATE
VAC(
HEALTH
PROJECTS
TAX
ISOC. sF:c.)
TAX
SDI
HOLIDAY
& WRI.F,
PENSION
I
S
1
TRAING,
FUND
DUES
"RAY)
SUBS.
SAVINGS
OTHER"
TOTAI.
UEUUC-
1
ADMIN
TWIN
r
0
I
THIS
ALL
FED.
FICA
STATE
VAC(
HEALTH :
PRU1L•(T
PROJECTS
TAX
ISOC. SEC.)
TAX
SDI
HOLIDAY
&WELF.
PENSION
t
S
I
E
TRAING,
FUND
DUES
TRAY
BURS.
SUBS.
SAVINGS
OTIFER'
TO
DEDUCONS-
E
ADMIN
TITAL
I
0
S - SI'IIAIOHT TIME 'OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Fume A-1-131 (Nsw 2-SH) O OVHRTINIH wage determinations must be sepnrately listed. Use extra shect(s) if necessary (Sea reverse Fide)
SUI = STA'I F I)NABILI'IY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1, Kristy South
(Name — print)
Controller
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLD 105 Certified Payroll, 2 pages
(Description, number of 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.
Date: 10/15/2019
Signature: �d
r
A public entity may require a stricter and/or more extensive form of certification.
_■;� Caiiromia PUBLIC WORKS PAYROLL REPORTING FORM
�+■ Deparum.t of
`� Industrial Rclalions
Page of
NAME OF CONTRACTOR: PWLC II, INC. CONTRACTOR'S LICENSE NO.: 855783 ADDRESS:3584 E Le Campana Way, Palm Springs CA 92202
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
1 PAYROLLNO,: 1 FINAL FORWF.EKPNDING: 10/20/2019 SELF -INSURED CERTIFICATE, NO.; PROJECTOR CONTRACT NO.:
COL0100 Le Fonda -Main & Monti
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO,: WSD 5029463 PROJECT AND LOCATION:
(1)
(2) I (3)
M T 1 W ;I F S S
(7)
(y)
(9)
NAME, ADDRESS AND
SOCIAL SECURITY NUMBER
OF EMPLOYEE
I
I WORK
CLASSIFICATION
o I
q�
OATS
TOTAL
HOURS
HOURLY
RATE
OF PAY
GROSS AMOUNT
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
NET WGS
PAID FOR
WEEK
CHECK
NO.
19 15 16 17 19 19 20
I
Y
HOURS WORKED EACH DAY
Hendquez, Ruben F
15887 Palm Dr#83
Desert Hot Springs CA 92240
0 11-andscape
I Maintenance
Laborer
i
S
8
B
15.00
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(6OC. SEC.)
STATE
TAX
SDI
VAC'
HOLIDAY
HEALTH
& \VELA.
PENSION
510.03
27247
120.00
645.00
64.90
49.34
14.26
6.45
0.00
0,00
0.00
1
TRAING.
FUND
ADMIN
DUES
THAW
SUBS,
SAVINGS
OTHER'
TOTAL.
DEDCC-
TIOIYS
1
1
0.00
0.00
0.00
0.00
0.00
0.00
134.97
1
0
Luna Gonzalez, Carlos
4 (Landscape
Maintenance
THIS
PROJECT
.
ALL
PRO]L•CTS
PFD
TAX
FICA
(60C. SEC.)
STATE
TAX
SDI
VAC!
HOLIDAY
HEALTH
&WELF.
PENSION
628.92
27248
88145 7th St
Desert Hot Springs CA 92240
I
Laborer
I
I
S
8
8
17'00
13
705.50
15.55
53.97
0.00
7.06
0.00
0.00
0.00
I
TRATNG.
FUND
ADMIN
DUES
TRAW
SUBS.DEDUC-
BAVINC9
OTHER'
TOTAL
TIUNS
0.00
0.00
0.00
0.00
0.00
0.00
76.58
I
0
I
THIS
PROTECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC, SEC.)
STATE
TAX
SDI
VACI
HOLIDAY
HEALTH
& WELF.
PENSION
l
S
1
TRAING.
FUND
ADMIN
DUES
THAW
SUBS,
SAVINGS
OTHER'
TOTAI,
DEDUC-
TIONS
1
!
!
0
i
I
THE
PROTECT
ALL
PROJECTS
F.
FED.
TAX
FICA
(S C SEC,)
STATE
9D1
HOLIDAY
& WEVACI LF
PENSION
1
S
1
TRAING.
FUND
ADMIN
DUES
TRAY/
SUBS.
SAVINGS
OTHER'
TOTAL
DEDCC-
'f1ON'S
1
1
1
i
0
S-STRAIGHT TIME 'ODIER-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Form A-1-131 (N-2-RO) U-OVERTIME wage determinations must be separately listed. Use extra sbeel(s) if necessary (See reverse side)
SDI - STATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1, Kristy South
(Name — print)
Controller
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLQ100 Certified Payroll, 2 pages
(Description, number of 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.
Date: 10/24/2019
Signature:'' e 10-Lct/
A public entity may require a stricter and/or more extensive form of certification.
l
d;mlCallfamio PUBLIC WORKS PAYROLL REPORTING FORM
Deportment of
industriol Relation 'I 2
Page of
NAME OFCONTRACIOR: PWLC II. INC
CONTRACTOR'S LICENSE NO.: 855783 ADDRESS: 3584 E La Campana Wav, Palm Springs CA 92262
OKSUBCONTRACTOK: - SPECIALITY
LICENSE NO,:
SELF -INSURED CERTIFICATE. NO.:
PROJECT OR CONTRACT NO,: �
I PAYROLL NO.: 1 FINAL FOR WEEK ENDING: 10/20/2019
(4) DAY (S) (6)
WORKERS'COMPENSATION POLICY NO.: WSD 5029463
PROTECT AND LOCATION: COLQ106 OurangolSonora on EIE
(1)
(2) I (3)
M I T I w TI F I S I S
(7)
(S)
(9)
NAME, ADDRESS AND
I
`� I WORK
DATE
TOTAL
HOURLY
RATE
GROSS AMOUNT
NET WGS
CHECK
14 15 16 17 16 19 20
SOCIAL SECURITY NUMBER
OF EMPLOYEE
c CLASSIFICATION
o i
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
WEEK
NO.
HOURS WORKED EACH DAY
F S 1
Henrlquez,Ruben F
15687 Palm Dr #83
Desert Hot Springs CA 92240
0 1 Landscape
iMaintenance
Laborer
I
I
s
8
8
8
8
32
15,00
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(ROC. SEC,)
STATE
TAX
SDI
VACI
HOLIDAY
HEALTH
@ELF.
PENSION
510.03
27247
525.00
845.00
64.90
49.34
14.28
6.46
0.00
0.00
0.00
1
0
.5
.5
1
2
22.5D
TitAINC,
FUND
ADMIN
DUES
SUBSS..I
SAVINGS
OTHER'
TOTAL
DEDUC-
TIONN
0.00
0.00
0,00
0,00
0,00
0.00
134.97
Lune Gonzalez, Carlos
66145 7th St
Desert Hot Springs CA 92240
If (Landscape
1 Maintenance
Laborer
I
g
8
8
8
8
32
17,00
THIS
PROJECT
ALL
PROJECTS
FED,
TAX
FICA
(SOC. SEC .)
STATE
TAX
SDI
VACI
110LIDAY
HEALTH
& WELF.
PENSION
628.92
27246
669.50
705.50
15.55
53.97
0.00
7.06
0.00
0.00
0.00
i
0
1
1
25,50
TRATNG.
FUND
ADMIN
DUMB
SUBS,
SAVINGS
OTIIF.R'
TOT
DEDUC-
770"
1
1
0,00
0.00
0.00
0.00
0100
0.00
76.58
Castillo,Margar0
68750 Ortega Rd
Cathedral Clly CA 92234
3 1 Landscape
iMalntenance
Laborer
i
S
8
8
8
24
17,00
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC.SEC.)
STATE
TAX
SDI
VACI
HOLIDAY
HEALTH
&ELF.
PENSION
376.58
6037
408.00
412.25
0.00
31.55
0.00
4,12
0.00
0.00
0.00
1
ry7lA1NG.
FUND
ADMIN
I DUBS
SUBS(
SAVINGS
OTHER'
TOTAL
DEDUC-
TInNS
I
1
0.00
0.00
0.00
0,00
0.00
0.00
35.67
o
Dimas, Pedro Reyes
31-900 Avenida El Mundo
Cathedral Clty CA 92234
1 ILendecepe
I Maintenance
1 Laborer
I
S
8
6
8
24
16.00FED.
THIS
PROJECT
ALL
PROJECTS
TAX
FICA
SOC fiEC.)
STAXE
SDI
IIOLI AVA Y
HEALTH
& ELF
PENSION
545.30
27246
384.00
640.00
33.23
48.96
6.11
6.40
0.00
0.00
0.00
TRAING.
FUND
ADMIN
DUES
TRAY/
RUBS.
SAVINGS
OTHER'
TOTAL
DEDUC-
TIONS
0.00
0.00
0.00
0.00
0.00
0.00
94.70
I
O
5 -STRAIGHT TIMH 'OTTER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be Completed
F-A-1-131 (New 2-Ra) o - OVERTIME wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SDI - STATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1, Kristy South
(Name — print)
Controller
(Position in business)
PWLC II, INC.
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
(Name of business and/or contractor)
that the records or copies thereof submitted and consisting of COL0106 Certified Paymli, 2 pages
(Description, number of 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.
Date: 10/24/2019
Signature: /111 ` /
A public entity may require a stricter and/or more extensive form of certification.
_�p� Colifumia PUBLIC WORKS PAYROLL REPORTING FORM
ii� Nporhnent of
Industrial ReInlions
Page of
' NAME OF CONTRACTOR: PWLC II, INC. CONTRACTORS LICENSE NO.: 855783 ADDRESS:3584 E La Campana Way, Palm Springs CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
PAYROLL NO.: 1 FINAL FOR WEEK ENDING: 10/27/2019 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ107 SONORNENSENADA
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: yySD 5029463 PROJECT AND LOCATION:
(1)
(2) 1 (3)
M T W TH F S S
(7)
(S)
(9)
DATE
HOURLY
NAME, ADDRESS AND
i 1 WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
21 22 23 1 29 2 5 2 6 2 7
SOCIAL SECURITY NUMBER
10 CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
OF EMPLOYEE
O Eo I
WEEK
HOURS WORKED EACH DAY
1
0 (Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
507.52
27360/6
Henrlquez, Ruben F
Maintenance
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
&Vi.ELF.
PENSION
043
15687 Palm Dr#83
(Laborer
S
8
8
8
24
15.00
382.50
640.82
63.95
49.01
13.93
6.41
0.00
0.00
0.00
Desert Hot Springs CA 92240
1
1
TRAINC.
FUND
DUES
SU�V/
SAVINGS
OTHER-
TOTAL
DED C-
1
1
1
1
22.50
ADMIN
TIDN4
I
O
0.00
0.00
0.00
0.00
0.00
0.00
133.30
4 1 Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
643.42
27361
Luna Gonzalez, Carlos
Maintenance
PROJECT
PROJECTS
TAX
I
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
66145 7th St
I
Laborer
s
6
8
8
24
17.00
433.50
723.32
17.33
55.34
0.00
7.23
0.00
0.00
0.00
Desert Hot Springs CA 92240
]
1
TRAING.
FUND
DUGS
SUBS.TRA
SAVINGS
OTHER'
TOTAL
DEDUC-
1
1
1
1
25.50
ADMIN
TIONS
i
0.00
0.00
0.00
0.00
0.00
0.00
79.90
1 1 Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
ItEALTII
545.30
27359
Dimas, Pedro Reyes
1Maintenance
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
&IYELP.
PENSION
31-900 Avenida El Mundo
Laborer
S
8
8
16.00
128.00
640.00
33.23
48.96
6.11
6.40
0.00
0.00
0.00
Cathedrel Clty CA 92234
I
I
]
TRAING,
DUGS
TRAY/
SUBS
SAVINGS
OTHER'
TOTAL
DEDUC-
]
.�MDN
TIONS
I
D
0.00
0.00
0.00
0.00
0.00
0.00
94.70
I
THIS
ALI,
FED.
FICA
STATE
VAC/
HEALTH
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
I
s
I
1
TRAING.
FUND
DUES
TRAY/ SUBS.
SAVINGS
OTHER"
TOTAL
DEDU]
ADnrIN
TInNS
TIDNS
1
0
S= STRAIGHTTIME •OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Foos A-1-UI(New 2-80) O=OVERTIME wage determinations must be separately listed. Use extra shect(s) ifneccssary (Sec reverse side)
SDI = STA7 E DISABILITY NSURANCE
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 Kristy South
(Name — print)
Controller
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLQ107 Ceriifed Payroll, 2 pages
(Description, number of 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.
Date: 10-30-2019
Signature: L-/?
A public entity may require a stricter and/or more extensive form of certification.
CAMIColiCamia PUBLIC WORKS PAYROLL REPORTING FORM
Deparancar of
1ndusirm[ Rciations,
Page
' NAME OF CONTRACTOR: PWLC Il, INC. CONTRACTOR'S LICENSE NO.: 855783 ADDRESS: 3584 E La Campana Way, Palm Springs CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
( PAYROLL NO.: 1 FINAL FOR WEEK ENDING: I0/27/2019 SELF -INSURED CERTIFICATE NO.: ORCONTRACT NO.:
TRCT
COLQ108 Tree Removal Jeffersol
(4) DAY (5) (6) WORKERS'COMPENSATION POLICY NO.: WSD 5029463 CT AND LOCATION:
(1)
(2) I (3)
M T I W TH F S S
(7)
(S)
(9)
DATE
HOURLY
NAME, ADDRESS AND
o [ WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
21 22 23 L241 25 26 2-7
SOCIAL SECURITYNUMBER
u- CLASSIFICATION
[
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID R
NO
OF EMPLOYEE
w0 0 �
WCK
°z [
uyj
HOURS WORKED EACH DAY
0 [Tree Maintenance
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
507.52
27360/6
Henrlquez,Ruben IF
PROJECT
PROJECTS
TAX
(,GC.SEC.)
TAX
SDI
HOLIDAY
&.WELF.
PENSION
G43
15687 Palm Dr #83
[Laborer
S
5
5
23.52
11.76
640.82
63.95
49.01
13.93
6.41
0.00
0.00
0.00
Desert Hot Springs CA 92240
[
TRAINC.
FUND
DUES
TRAY
SAVINGS
OTHER'
TOTAL
DEDUC-
1
T
ADMIN
IONR
I
o
0.00
0.00
0.00
1 0.00
0.00
0.00
133.30
4 [Tree Maintenance
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
643.42
27361
Luna Gonzalez, Carlos
Laborer
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
[
S
5
5
23,52
11.76
723.32
17.33
55.34
0.00
7.23
0.00
0.00
0.00
Desert Hot Springs CA 92240
I
1
TRAINC,
FUND
DL'E.S
TRAV/
SUES.
SAVINGS
OTHER-
TOTAL
DEDUC-
J
[
ADMIN
TIONS
[
O
0.00
0.00
0.00
0.00
0.00
0.00
79.90
0 1 Tree Maintenance
THIS
ALL
FED.
FICA
STATE
VAC!
HEALTH
507.52
27360/6
Henriquez, Ruben F
[ Laborer
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& W'ELF.
PENSION
043
15687 Palm Dr#83
S
5
.5
20.62
10.31
640.82
63.95
49.01
13.93
6.41
0.00
0.00
0.00
Desert Hot Springs CA 92240
[
TOTAL
TRAINC.
FUND
DUES
SUBS./
SAVINGS
OTHER-
DEDUC-
T
ADMIN
TIONS
I
0.00
0.00
0.00
0.00
0.00
0.00
133.30
4 1Tree Maintenance
THIS
ALL
FED.
FICA
STATE
VACI
HEALTH
643.42
27361
Lunde Gonzalez, Carlos
1 Laborer
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
&WELF.
PENSION
66145 7th St
g
.5
.5
20.62
10.31
723.32
17.33
55.34
0.00
7.23
0.00
0.00
0.00
Desert Hot Springs CA 92240
I
TOTAL 7
TRAING.
FUND
DUES
SUBS./
SAVINGS
OTHER'
DEDUC-
ADMIN
TIOXS
O
0.00
0.00
0.00
0.00
0.00
0.00
79.90
s- s'rRAIGHTTISIL 'OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Farm A-1-131 (New 2-90) 0 = OVERTIME wage determinations must be scpamtely listed. Use extra shect(s) if necessary (See reverse side)
SDI - STATE DISAIIILITY INSURANCE
NOTICE TO PUBLIC ENUTY
For Privacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1, Kristy South
(Name — print)
Controller
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLQ108 Certified Payroll, 2 pages
(Description, number of 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.
Date: 10-30-2019
Signature: �-ba� / 1'0'
A public entity may require a stricter and/or more extensive form of certification.
L
1
I CAR
PUBLIC WORKS PAYROLL REPORTING FORM
Depanownt of
1 Industrial Relations 1
Page of
1 NAME OF CONTRACTOR: PWLC II, INC. CONTRACTORS LICENSE NO.: 855783 ADDRESS:3584 E La Campana Way, Palm Springs CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO-:
I PAYROLL NO.: 1 FOR WEEK ENDING: 10/27/2019 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
(4) DAY (5) (G) WORKERS' COMPENSATION POLICY NO.: tgl$D 5029463 PROTECT AND LOCATION: COLQ102 P#600-340-047 ADAM'
(D
NAME, ADDRESS AND
SOCIAL SECURITY NUMBER
OFEMPLOYEE
(2) i (3)
F WORK
suo CLASSIFICATION
G j �J I
M T 1 W TH F S S
TOTAL
HOURS
HOURLY
RATE
OF PAY
(7)
GROSS AMOUNT
EARNED
(g)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
DATE
NET WGS
PAID FOR
WEEK
CHECK
NO.
21 22 23 1 29 25 26 27
j z (a
HOURS WORKED EACH DAY
Henriquez, Ruben F
15687 Palm Dr483
Desert Hot Springs CA 92240
O ILandscape
I Maintenance
Laborer
I
I
S
8
a
15.00
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(soc.SEC.)
STATE
TAX
SDI
VAC/
HOLIDAY
HEALTH
&WELF.
PENSION
507.52
2736016
043
131.25
640.82
63.95
49.01
13.93
6.41
0.00
0.00
0.00
I
T
I
0
cJ
•5
22.50
TRAING.
FUND
ADMIN
DUES
V
SUBS!
SAVINGS
OTHER'
TOTAL
DEDUC-
TIONS
0.00
0.00
0.00
0.00
0.00
0.00
133.30
Luna Gonzalez, Carlos
4 I Landscape
I Maintenance
THIS
PROJECT
ALL
PROJECTS
FED,
TAX
FICA
(SOC. SEC.)
S'rATE
TAX
SDI
VAC/
HOLIDAY
HEALTH
& WELF.
PENSION
643A2
27361
66145 7th St
Desert Hot Springs CA 92240
Laborer
1
s
8
8
17.00
148.75
723.32
17.33
55.34
0.00
7.23
0.00
0.00
0.00
I
D
5
-5
25.50
TRAUNC.
FUND
ADMIN
DUES
SUBS.
SAVINGS
OTHER•
TOTAL
DEDUC-
TIONS
E
I
0.00
0.00
0.00
0.00
0.00
0.00
79.90
I
THIS
PROJECT
ALL
PROJECTS
D.
�%
FICA
(S SEC. )
STATE
SDI
H VAD AV
HEALTH
PENSION
1
S
1
TRAING.
AFUNDDMIN
DUES
SI BS
SAVINGS
OTHER'
DEDUC-
TIONS
1TOTAL
I
I
O
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VAC/
HOLWAY
HEALTH
& wELF.
PENSION
I
S
I
T
TRAING.
FUND
ADMIN
DUES
SDI`./
SAVINGS
OTHER'
TOT
DEDUC-
TIONS
0
S=STRAIGHTTI.ME•. 'OTHER- Any other deductions, contributions and/or payments whether or not included or required by prevai l ing CERTIFICATION MUST he completed
Form A-I-131 (New 2-00) o=OVERTIME wage determinations must be separately listed. Use extra shect(s) if necessary (Sec reverse side)
SDI = STAI E DISABILITY INSURANCE:
0
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 Kristy South
(Name — print)
Controller
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
_. the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLQ102 Certified Payroll, 2 pages _ _
(Description, number of 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.
Date: 10-30-2019
Signature: :7el
�G
A public entity may require a stricter and/or more extensive form of certification.
CiRCalifornia PUBLIC WORKS PAYROLL REPORTING FORM
Dapartm rt of
Industrial Relations
Page of
t NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO.: ADDRESS:
I PWLC II, INC. 855783 3584 E La Campena Way, Palm Springs CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
I PAYROLL NO.: 1 FINAL FOR W EEK ENDING: 11 /3/2019 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ102 Pg600-340-047 ADAM'
(4) DAY (5) (S) WORKERS' COMPENSATION POLICY NO.: WSD 5029463 PROJECT AND LOCATION:
(1)
(2) 1 (3)
M T W TH F S S
(7)
(E)
(9)
HOURLY
NAME, ADDRESS AND
pc ? I WORK
DATE
TOTAL
RATE
GROSS AMOUNT
NET WGS
CIIECK
28 2 9 30 31 O 1 02 03
SOCIAL SECURITY NUMBER
5 E o CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
E Y
I
O p
WEEK
I
11
HOURS WORKED EACH DAY
4 1 Landscepe
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
649.67
27395
Lune Goncalez, Carlos
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
&wELF.
PENSION
66145 7th St
(Maintenance
Laborer
g
8
B
17.DO
Desert Hot Springs CA 92240
I
136.00
731.00
18.10
55.92
0.00
7.31
0.00
0.00
0.00
/
TOT
TRAINC.
FUND
DUES
SUBS
SAVINGS
OTHER"
DEDUC-
ADMIN
TIOMS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
81.33
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& wELF.
PENSION
I
S
t
TRAY/
TOTAL
TRAING.
FUND
DUES
SUBS.
9AVINCS
OTHER"
DEDUC-
T
ADMIN _
TIONS
I
0
I
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
1
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
S
I
W
TOTAL
TRAJNG.
FUND
DUES
SUBS.
SAVINGS
OTHER'
TIONS
1
0
TITIS
ALL
FED.
FICA
STATE
VACI
HEALTH
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
i
s
1
i
TRAING.
FUND
DUES
SUBS.
SAVINGS
OTIH:R"
DEDUC-
1
ADMIN
TIONS
I
0
S=SrRAIGHTTI.NE 'OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Farm A.I-131 (New 2-80) o= OVERTIME wage determinations must be separately listed. Use extra shecl(s) if necessary (See reverse side)
SDI =- STATE DISABILITY 114SURANCE
NOTICE TO PUBLIC ENTITY
For Privacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 Kristy South
(Name — print)
Controller
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL0102 Certied Payroll, 2 pages
(Description, number of 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.
Date: 11-6-2019
Signature: _
A public entity may require a stricter and/or more extensive form of certification.
California PUBLIC WORKS PAYROLL REPORTING FORM
Dcpmtnvnt of
Induslrinl Relations
Page
NAME OF CON'IR ACTOR: CONTRACTORS LTCENSE NO.: ADDRESS:
I PWLC II, INC. 855783 3584 E La Campana Way, Palm Springs CA 92262
OR $U73C'ON7'RA["I'UR; SPECIALITY LICENSE NO.:
1 PAYROLLNO.: 1 FINAL FOR WEEK ENDING: 11/3/2019 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
C0LQ103 P#600-340-029 ADAMI
(4) DAY (S) (6) WORKERS' COMPENSATION POLICY NO: VdSD 5029463 PROTECT AND LOCATION:
DATE
HOURLY
NAME, ADDRESS AND
�C WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
28 29 30 31 O1 02 q3
SOCIAL SECURITY NUMBER
5v0 CLASSTFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO -
OF EMPLOYEE
P 1
WEEK
i o I
HOURS WORKED EACH DAY
0 (Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
DEALTII
526.88
27394
Henrlquez, Ruben F
Malntenance
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
&WELF.
PENSION
15687 Palm Dr#83
ILaborer
S
8
8
15.00
120.00
667.50
67.60
51.07
15.27
6.68
0.00
0.00
0.00
Desert Hot Springs CA 92240
1
TRAiNC.
FUND
DUES
SUBS/
SAVINGS
OTHER"
TOTAL
DEDUC-
1
ADMIN
TTONS
I
D
0.00
0.00
0.00
0.00
0.00
0.00
140.62
4 (Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
649.67
27395
Luna Gonzalez, Carlos
Maintenance
PROJECT
PROJECTS
TAX
(SUC. SEC.)
TAX
SDI
IT
& WELF.
PENSION
66145 7th St
1
Laborer
S
8
8
17.00
136.00
731.00
18.10
55.92
0.00
7.31
0.00
0.00
0.00
Desert Hat Springs CA 92240
I
Y
TOTAL
TRAING.
FUND
DUES
SUUBBSS.
SAVINGS
OTHER"
DEDUC-
T
ADMEN
TTONS
)
O
0.00
0.00
0.00
0.00
0.00
0.00
81.33
0 11-andscape
TH1S
ALL
FED.
FICA
STATE
VAC/
HEALTH
586.85
27398
Valdez Cisneros, Salvador
Maintenance
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
12966 Cactus Dr
1
Laborer
S
8
8
15.00
120.00
667.50
17.58
51.06
5.33
6.68
0.00
0.00
0.00
Desert Hot Springs CA 92240
1
1
V
TOTAL
I
TRATNG.
FUND
DUES
SU119TRA/
SAVINGS
OTHER"
DEDUC-
T
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
80.65
4 I
TT77S
ALL
EEO.
FICA
STATE
\'AC/
HEALTH
1
PROJECT
PROTECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
1
S
I
1
AVI
TRATNG.
FUND
DUES
SUUBS.
SAVINGS
OTHER"
DEDUC-
1
ADMIN
TIn .S
I
D
S=STRAIGHTTIME OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Form A-I-131 (New 2-00) O=OVERTIME wage determinations must be separately listed. Use extra shect(s) if necessary (Sec reverse side)
SDI = STATE DISABILITY INSURANCE.
NOTICE TO PUBLIC ENTITY
For Privacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 Kristy South , the undersigned, am the
(Name — print)
Controller with the authority to act for and on behalf of
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLO103 Certified Payroll. 2 pages
(Description, number of 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.
Date: 11-6-2019
Signature:
A public entity may require a stricter and/or more extensive form of certification.
CHI amie
Dcpr
Dcpetrnent of
Indushial Relations
PUBLIC WORKS PAYROLL REPORTING FORM
1 2
Page of_
I NAME OF CONTRACTOR: PWLC Il, INC. CONTRACTOR'S LICENSE NO,: 855783 ADDRESS:3584 E La Cempena Way, Palm Springs CA 92262
t OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
I PAYROLL NO.: 1 FINAL FOR WEEK ENDING: 1113/2019
SELF -INSURED CERTIFICATE NO.:
PROJECT OR CONTRACT NO.:
COLO104 P#600-340-046 ADAW
(4) DAY (5) (6)
WORKERS' COMPENSATION POLICY NO.: y�/SD 5029463
PROTECT AND LOCATION:
(1)
(2) 1 (3)
M T I W TH F S F1
(7)
(g)
(9)
DATE
I
HOURLY
NAME, ADDRESS AND
7 WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
2 B 2 9 30 31 01 02 09
SOCIAL SECURITY NUMBER
; u o CLASSIFICATION
1
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
OF EMPLOYEE
o o �
WEEK
HOURS WORKED EACH DAY
1
0 1 Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
IWALTH
526.88
27394
Henriquez, Ruben F
PROJECT
PROJECTS
TAX
(SOC.SECJ
TAX
SDI
HOLIDAY
&WELF.
PENSION
15687 Palm Dr#83
(Maintenance
Laborer
S
8
8
16
1S.00
Desert Hot Springs CA 92240
1
273.75
667.50
67.60
51.07
15.27
6.68
0.00
0.00
0.00
TRAY/
TOTAL
TRAING.
FUND
DUES
SUBS.
SAVINGS
OTHER•
DEDUC-
I
1.5
22.50
ADMIN
TIONS
I
D
.5
1
0.00
0.00
0.00
0.00
0.00
0.00
140.62
4 1 Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
649.67
27395
Luna Gonzalez, Carlos
Maintenance
PROJECT
PROJECTS
TAX
ISSEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
66145 7th St
I
Laborer
S
8
8
17.00
Desert Hot Springs CA 92240
1
148.75
731.00
18.10
55.92
0.00
7.31
0.00
0.00
0.00
1
THAW
TOTAL
I
TRAING.
FUND
DUES
SUBS.
9AVINC5
OTHER'
DEDUC-
1
ADMIN
TIONS
O
,5
.5
25.50
1
0.00
0.00
0.00
0.00
0.00
0.00
81.33
0 11-andscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
586.85
27396
Valdez Cisneros, Salvador
Maintenance
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLHDAV
& WELF.
PENSION
12966 Cactus Dr
1
Laborer
S
8
8
16
15,00
Desert Hot Springs CA 92240
1
273.75
667.50
17.58
51.06
5.33
6.68
0.00
0.00
0.00
1
TRAING.
FUND
DUES
SUBS.Y/
SAVINGS
OTHER•
DEDUC-
T
ADMINTIONS
I
O
.5
1
1.5
22.50
0.00
0.00
0.00
0.00
0.00
0.00
80.65
4 1
THIS
ALL
FED.
FICA
STATE
VAC!
HEALTH
1
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
I
S
1
THY/
TOTAL
1
TAAINC.
FUND
DUES
. SUBS
SAVINGS
OTHER'
DEDUC-
1
ADMIN
TIONS
1
D
S=STRAIGHTTI.ME •OTHER- Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
ro-A-1-131 (N2-80) O= OVERTIME wage determinations must be separately listed. Use extra shect(s) ifnecessary (Sec reverse side)
SDI STATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 Kristy South
(Name — print)
Controller
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
.. the undersigned, am the
with the authority to act for and on behalf of
, certify under penalty of perjury
that the records or copies thereof submitted and consisting of GOLQ104 Certified Payroll, 2 pages
(Description, number of 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.
Date: 11-6-2019
Signature:
A public entity may require a stricter and/or more extensive form of certification.
�■�� Califomiu PUBLIC WORKS PAYROLL REPORTING FORM
i�l� Deparfiant of
Industrial ReLitions
Page
I
NAME OF COti7RA11IR: CONTRACTOR'S LICENSE. NO,: ADDRESS:
PWLC II, INC. 855783 3584 E La Campana Way, Palm Springs CA 92262
OR SU BCi7N'I'RAL"f OH; SPECIALITY LICENSE NO.:
PAYROLLNO.: 1 FINAL FORWEEKENDING: 11/10/2019 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COL0110 ENSENADA/NOGALE;
(4) DAY (1) (6) WORKERS' COMPENSATION POLICY NO.: WSD 5029463 PROJECT AND LOCATION:
(1)
(2) 1 (3)
M T VI F S S
(7)
(8)
(9)
NAME, ADDRESS AND
SOCIAL SECURITY NUMBER
OF EMPLOYEE
1
iO I WORK
yCLASSIFICATION
e a 1
DATE
HOURS
HOURLY
HOURLY
RATE
OF PAY
GROSS AMOUNT
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
NET WGS
PAID FOR
WEEK
CHECK
NO
09 OS 06 07 0B 09 10
HOURS WORKED EACH DAY
z I
Henriquez, Ruben F
15687 Palm Dr#83
Desert Hot Springs CA 92240
0 ILandscape
Maintenance
(Laborer
1
s
8
8
8
8
32
15.00
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VAC/
HOLIDAY
HEALTH
& WELF.
PENSION
657.01
27427
513.75
847.50
90.73
64.83
26.45
8.48
0.00
0.00
0.00
I
°
1
,5
1.5
22.50
TRATNQ
FUND
ADMIN
DUES
SPAS/
SUBS.
SAVINGS
OTHER'
DEDUTOTAL
TION9 -
TION9
1
1
1
0.00
0.00
0.00
1 0.00
0.00
0.00
190.49
Luna Gonzalez, Carlos
66145 7th St
Desert Hot Springs CA 92240
1 Landscape
/� IMainlenance
r Laborer
1
I
S
a
8
8
8
32
17.00
THIS
PROJECT
ALL
PROJECTS
FED,
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VAC/
HOLIDAY
HEALTH
&{VELF.
PENSION
618.55
27428
556.75
692.75
14.28
52.99
0.00
6.93
0.00
0.00
0.00
°
5
5
25.50
TRAING.
FUND
ADMIN
DUES
SUBS/
SAVINGS
OTHER"
TO AL
DEDUC-
TIONS
T
I
0.00
0.00
0.00
0.00
0.00
0.00
74.20
Valdez Cisneros, Salvador
0 ILandscape
Maintenance
THIS
PROJECT
ALL
PROJECTS
FED,
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VAC/
If
IJEALTII
& {SELF.
PENSION702.66
27429
12966 Cactus Dr
Desert Hot Springs CA 92240
1
Laborer
1
s
8
8
8
8
32
15.00
513.75
858.75
68.36
65.70
13.42
8.59
0.00
0.00
0.00
1
°
1
,5
1.5
22.50
TRAINC.
FUND
ADMIN
DUES
THAW
SAVINGS
OTHER'
TOTAL
DEDUC-
T10NS
1
T
1
0.00
0.00
0.00
0.00
0.00
0.00
156.07
Dimes, Pedro Reyes
31-900 Avenida El Mundo
Cathedral City CA 92234
1 ILandscape
I Maintenance
Labor
1
S
8
8
8
24
16.00
THIS
PROJECT
ALL
PROJECTS
FED,
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VAC/
HOLIDAY
HEALTH
& WELF.
PENSION
554.81
27426
396.00
652.00
34.43
49.87
6.37
6.52
0.00
0.00
0.00
1
I
I
O
.5
.5
24.00
TRAING.
FUND
ADMIN
DUES
RAVI
SUBS.
SAVINGS
OTHER'
TOTAL
DEOUC-
TIONS
0.00
0.00
0.00
0.00
0.00
0.00
97.19
S - STRAIGHT TIME 'OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Form A-1-131 (New 2.80) O - OVERTIME wage determinations must be separately listed. Use extra shect(s) if necessary (See reverse side)
SDI - SPATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 Kristy South , the undersigned, am the
(Name - print)
Controller with the authority to act for and on behalf of
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL0110 Er. -�rriada/Nogales at Eisenhower
(Description, number of 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.
Date: 11-15-2019
Signature: '4-tL46
61 -
A public entity may require a stricter and/or more extensive form of certification.
_,■;� Calif mla PUBLIC WORKS PAYROLL REPORTING FORM
ii DcpaMunt of
Industrial Relations
Page of
1 NAME OF CONTRACTOR: PWLC II, INC. CONTRACTOR'S LICENSE NO.: 855783 ADDRESS:
35B4 E La Campana Way, Palm Springs CA 92262
OR SUBCON rRACTOR: SPECIALITY LICENSE NO.;
1 PAYROLLNO.: 1 FINAL FORWEEKENDING: 11/24/2019 SELF -INSURED CERTIFICATE NO.: OR CONTRACT NO.:
7PROIECT
COL0111 NOGALESICHIHUAHU
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO: WSD 5029463ROJECT AND LOCATION:
DATE
NFT WGS
PAID FOR
CHECK
NO.
NAME, ADDRESS AND
SOCIAL SECURITY NUMBER
OF EMPLOYEE
II
WORK
FOOL ` CLASSIFICATION
,F.WEEK
1
TOTAL
HOURS
HOURLY
RATE
OF PAY
GROSS AMOUNT
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
18 19 20 21 22 23 24
j
HOURS WORKED EACH DAY
Hendquez, Ruben F
15687 Palm Dr #83
Desert Hot Springs CA 92240
0 I Landscape
I Maintenance
Laboror
I
S
B
8
B
8
8
40
15.00
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VAC(
HOLIDAY
HEALTH
& WELF.
PENSION
518.45
27569
656.25
656.25
66.25
50.22
14.77
6.56
0.00
0.00
0.00
O
1
5
-5
.5
2.5
22.50
TRAING.
FUND
ADMLN
DUES
SUBS./
SAVINGS
OTHER'
TOTAL
DEDUC-
TIONS
:
I
r
0.00
0.00
0.00
0.00
1 0.00
0.00
137.80
Luna Gonzalez, Carlos
66145 7th St
Desert Hot Springs CA 92240
4 1 Landscape
1 Maintenance
Laborer
I
S
8
8
8
8
8
40
17.00
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VAC!
HOLIDAY
HEALTH
& WELF.
PENSION
649.67
27570
731.00
731.00
18.10
55.92
0.00
7.31
0.00
0.00
0.00
°
.5
.5
.5
.5
2
25.50
TRAING.
FUND
ADMIN
DUES
TRAYI
SUBS.
SUBS.
SAVINGS
OTHER'
TOTAL
DEDUC-
TIONS
IONS
1
1
0.00
0.00
0.00
0.00
0.00
0.00
81.33
Valdez Cisneros, Salvador
12966 Cactus Dr
Desert Hot Springs CA 92240
0 ]Landscape
I Maintenance
Laborer
I
I
S
8
8
8
8
8
40
15.00
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VAC/
HOLIDAY
HEALTH
& WELF.
PENSION
676.66
27571
645.00
825,00
64.31
63.11
12.67
8.25
0.00
0.00
0.00
I
t
1
I
p
1
.5
.5
2
22.50
TRAING.
FUND
ADMIN
DUES
Ste/
SAVINGS
OTHER'
TOTAL
DEDUC-
TIONc
0.00
0.00
0.00
0.00
0.00
0.00
148.34
Dimas, Pedro Reyes
31-900 Avenlde El Mundo
Cathedral City CA 92234
:Landscape
, 1 Maintenance
Labor
1
S
8
8
8
8
8
40
16.00
THIS
PROJECT
ALL
PROJECTS
FED,
TAX
FICA
ISOC. SEC.)
STATE
TAX
SDI
VACI
HOLrDAY
HEALTH
& WELF.PENSION
564.29
27568
664.00
664.00
35.63
50.80
6.64
6.64
0.00
0.00
0.00
:
O
.5
.5
1
24.00
TRAING.
FUND
ADMIN
DUES
SUBS.TRAY
SUBS.
SAVINGS
OTHER'
TOTAL
DEDUC-
TIONS
I
1
0.00
0.00
0.00
0.00
0.00
0.00
99.71
S=STRAIGHT TIME -OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Fora, A-1-171 (New 2-s0) o = OVERTIME wage determinations must be separately listed. Use extra shect(s) if necessary (Sec reverse side)
SDI = STAT E DISABILITY INSURANCE
M
NOTICE TO PUBLIC ENTITY
For Privnev Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 Kristy South
(Name — print)
Controller
(Position in business)
PWLC Il, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
, certify under penalty of perjury
p
that the records or copies thereof submitted and consisting of COL0111 Nogales/Chihuahua at Eisenhower Z pa .9g
(Description, number of 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.
Date: 11-29-2019
Signature: J-� Z 'f Aa-e&
A public entity may require a stricter and/or more extensive form of certification.
4121 California PUBLIC WORKS PAYROLL REPORTING FORM
Department of
Industrial Relallow
Page
' NAME OF CONTRACTOR: PWLC 11, INC. CONTRACTOR'S LICENSENO.: ADDRESS:
855783 3584 E La Campana Way, Palm Springs, CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO,:
1 PAYROLLNO.: 1 FINAL FOR WEEK ENDING: 12/08/2019 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ112 CHIHUAHUA/MONTEF
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: W$D 5029463 PROJECT AND LOCATION:
(I)
(2) 1 (3)
M I T I W TH I F I S I S
(7)
(E)
(9)
DATE
NET WGS
CHECK
NAME, ADDRESS AND
1
� � 1 WORK
TOTAL
HOURLY
RATE
GROSS AMOUNT
02 03 09 OS 06 07 08
SOCIAL SECURITY NUMBER
sod CLASSIFICATION
1
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
OF EMPLOYEE
c O
WEEK
HOURS WORKED EACH DAY
Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
IIEALTII
436.95
27716
Henriquez, Ruben F
Maintenance
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& NELF.
PENSION
15687 Palm Dr#83
I
Laborer
s
8
8
8
8
32
15.00
547.50
547.50
53.20
41.88
9.99
5.48
0.00
0.00
0.00
Desert Hot Springs CA 92240
1
I
TRAINC.
FUND
DUES
TRAY/
SUBS,
SAVINGS
OTHER"
TOTAL
DEDUC-
1
3
22.50
ADMIN
TrD^
I
0
0.00
0.00
0.00
0.00
0.00
0.00
110.55
1 1 Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
427.58
27717
Lepez, Juan M
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
&PELF.
PENSION
13146 Nilsen Ct
1Maintenance
Laborer
S
a
8
8
24
15.00
371.25
491.25
18.36
37.57
2.83
4.91
0.00
0.00
0.00
Beaumont CA 92223
1
1
TRAING.
FUND
DUESTRAM/
SUBS.
SAVINGS
TO TOTAL
1
I
22.5
ADMIN
TIO. SDEDUC-
�
0
.5
.5
0.00
0.00
0.00
0.00
0.00
0.00
63.67
4 ;Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
539.03
27718
Luna Gonzalez, Carlos
Maintenance
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
66145 7th St
Laborer
S
8
8
8
8
32
17.00
595.00
595.00
4.50
45.52
0.00
5.95
0.00
0.00
0.00
Desert Hot Springs CA 92240
1
TRAING.
FUND
DUES
TRAY/
SUBS
SAVINGS
OTHER'
TOTAL
pEDUC-
1
ADMIN
TIONS
O
,5
.5
1
2
25.50
0.00
0.00
0.00
0.00
0.00
0.00
55.97
1
m 11-andscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
461.51
27719
Valdez Cisneros, Salvador
1 Maintenance
PROJECT
PROJECTS
TAX
ISSEC,)
TAX
SDI
HOLIDAY
& WELF.
PENSION
12966 Cactus Dr
Laborer
S
8
8
8
8
32
15.00
547.50
547.50
32.06
41.88
6.57
5.48
0.00
0.00
0.00
Desert Hot Springs CA 92240
1
I
TRAING.
FUND
DUES
TRAY/
SUBS
SAVINGS
OTIBER•
TOTAL
DEDUC-
J
1
1
1
3
22,50
ADMIN
T10NS
1
O
.5
.5
0.00
0.00
0.00
0.00
0.00
0.00
85.99
S = STRAIGHT TIME -OTHER-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Farm A-I-LI I f l,1 ?2 0) O = OVERTIME wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SDI = STATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 Kristy South
(Name — print)
Controller
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
a 6ti
that the records or copies thereof submitted and consisting of GOLp112 Ghihuahua/Mon[erey on Eisenhower ,2 P .1
(Description, number of 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.
Date: 1 2/13/2019
Signature: �&
A public entity may require a stricter and/or more extensive form of certification.
Cal+Ia'nia PUBLIC WORKS PAYROLL REPORTING FORM
Departnent of
Jill
Industrial Relations
Page Of -
NAME OF CONTRACTOR: PWLC ll, INC. CONTRACTOR'S LICENSE NO.: ADDRESS:3584
855783 E La Campana Way, Palm Springs, CA 92262
OR SUBCONTItAC-FOR: SPECIALITY LICENSE NO:
I PAYROLL NO.: 1 FINAL FOR WEEK ENDING: 12/15/2019 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ119 AVE FERNANDO E SII
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: W$D 5029463 PROJECT AND LOCATION:
(I)
(2) t (3)
M I T I W TH F S S
(7)
(S)
(9)
I
HOURLY
DATE
NAME, ADDRESS AND
I WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
0 9 111 11 12 13 19 15
SOCIAL SECURITY NUMBER
u CLASSIFICATION
E I
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAR) FOR
NO.
OFFEMPLOYEE
C
WEEK
HOURS WORKED EACH DAY
o I
3 1 Landscape
THIS
ALL
FED,
FICA
STATE
VAC/
ALTH
HEALTH
338.72
27848
Diaz Ortega, Carmelo
Maintenance
PROJECT
PROJECT$
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
&
PENSION
33583 Navajo Tr
I
Laborer
s
8
8
6
22
12 36
271.92
370.80
0.00
28.37
0.00
3.71
0.00
0.00
0.00
Cathedral City CA 92234
1
l
TRAING.
FUND
DUES
TRAM
SUBS.
SAVINGS
OTHER'
TOTAL
DEDUC-
1
T
ADMEN
TIONS
l
o
0.00
0.00
0.00
0.00
0.00
0.00
32.08
1 1 Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
564.29
27632
Dimas, Pedro Reyes
Maintenance
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
31-900 Avenida El Mundo
I
Laborer
S
8
8
8
8
8
40
16.00
664.00
664.00
35.63
50.80
6.64
6.64
0.00
0.00
0.00
Cathedral City CA 92234
1
l
TRAING,
FUND
DUES
TRAY/
SUBS,
SAVINGS
OTHER'
TOTAL
DEDU
1
24.00
ADMEN
TIO. `C-
I
G
1
0.00
0.00
0.00
0.00
0.00
0.00
99.71
5 (Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
644.73
27846
Vargas, Genaro
1Maintenance
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
&{PELF.
PENSION
69130 Victoria Dr
Laborer
S
B
8
16
13.00
403.00
715.00
8.42
54.70
0.00
7.15
0.00
0.00
0.00
Cathedral City CA 92234
1
TRAING.
FUND
DUES
S BS.
SAVINGS
OTHER"
TOTA
DEDUC-
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I
ADMEN
•PIONS
I
O
1
1
8
10
19.50
-
0.00
0.00
0.00
0.00
0.00
0.00
70.27
1 lLandscape
THIS
ALL
FED.
FICA
srATE
VAC/
HEALTH
27834
Lepez, Juan M
I Maintenance
PROJECT
PROJECTS
TAX
ISOC. SEC.)
TAX
SDI
HOLmAY
& WELF.
PENSION'
13146 Nilsen Ct
Laborer
s
8
8
16
15.00
240.00
600.00
Beaumont CA 92223
l
29.23
45.91
5.23
6.00
0.00
0.00
0.00
TRAING.
FUND
DUES
SUBS./
SAVINGS
OTHER'
DEDUC-
1
ADMEN
TINNS
C
O
0.00 1
0.00
0.00
0.00
0.00
0.00
86.37
S- STRAIGHT TINE •OTHER- Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
R,rm A-1-111 INaw2401 O-OVERTIME Wage detcrnninatiunS must be separately listed. Use extra shcct(s) if necessary (Sea reverse side)
SDI = STATE DISABILITY INSURANCE
_■;� Califomi. PUBLIC WORKS PAYROLL REPORTING FORM
ii Depernnent of
Industrial Relations
Page
NAME DFCONTRACTORt PWLC 11, INC. CONTRACTOR'S LICENSE NO.: 855783 ADDRESS:3584 E La Campana Way, Palm Springs, CA 92262
OR SVIICONTRACTOR: SPECIALITY LICENSE NO.:
PAYROLL NO.: 1 FINAL FOR WEEK ENDING: 12/15112019 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLO119 AVE FERNANDO E Sit
(4) DAY (5) (6) WORKERS'COMPENSATION POLICY NO.: WSD 5029463 PROJECT AND LOCATION:
(l)
(2) 1 (3)
M I T W TH I F I S I S
(7)
(g)
(9)
DATE
1
HOURLY
NAME, ADDRESS AND
H 1 WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
09 10 11 12 13 19 15
SOCIAL SECURITY NUMBER
a c7 c CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
OF EMPLOYEE
C o �y 1
1
WEEK
i z c7-
HOURS WORKED EACH DAY
D 1 Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
REALT11
510.03
27833
Henrlquez,Ruben F
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
&WELP.
PENSION
15687 Palm Dr#83
IMa11116nance
S
8
8
8
24
1S.00
382.50
645.00
64.90
49.34
14.28
6.45
0.00
0.00
0.00
Desert Hot Springs CA 92240
ILabOfor
I
TRAINC.
FUND
DUES
SI BS /
SAVINGS
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TOT
DEDUC-
1
1
22.50
ADMLN
TIONS
1
0
0.00
0.00
0.00
0.00
0.00
0.00
134.97
4 (Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
649.68
27835
Luna Gonzalez, Carlos
Maintenance
PROJECT
PROJECTS
TAX
(Soc. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
66145 7th St
(
Laborer
S
8
8
8
24
17.00
433.50
731.00
18.10
55.91
0.00
7.31
0.00
0.00
0.00
Desert Hot Springs CA 92240
1
TRAING.
FIND
DUES
SUAV/
sues.
SAVINGS
OTHER'
TOT L
DEDU C
1
1
1
1
25.50
ADMIN
TIONS
I
G
0.00
0.00
0.00
0.00
0.00
0.00
81,32
0 1 Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
676.67
27836
Valdez Cisneros, Salvador
I Maintenance
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
12966 Cactus Dr
Laborer
s
8
8
8
24
15.00
562.50
825.00
64.31
63.10
12.67
8.25
0.00
0.00
Desert Hot Springs CA 92240
I
1
TRAING,
FUND
DUES
TRAY
SUBS
SAVINGS
OCHER"
JDEDUC-
1
ADMIN
1p
1
1
7
9
22.50
0.00
0.00
0.00
0.00
0.00
0.00
4 ILandscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
584.86
27849
Rojas Mendez, Carlos
1 Maintenance
PROJECT
PROJECTS
TAX
SOC. SEC.)
TAX
SDI
HOLIDAY
&wELF.
PENSION
30224 San Luis Rey Cr
Laborer
S
8
8
16
12.36
383.16
679.80
Cathedral City CA 92234
1
30.31
52.00
5.83
6.80
0.00
0.00
0.00
1
TRAING.
FUND
DUES
SUBS./
SAVINGS
OTHER'
TOTAL
DEDUC-
1
1
1
6
10
16.54
ADMrN
MONS
1
O
0.00
0.00
0.00
0.00
0.00
0.00
94.94
S = STRAIGHT TIME rOrHER-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Form A-I-131 (Nero ]-SO) O= OVERTIME rouge detemlinations must be separately listed. Use extra shect(s) if necessary (See reverse side)
SDI - STATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 Kristy South
(Name — print)
Controller
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
Q e S
that the records or copies thereof submitted and consisting of COLQ119 AVE FERNANDO E SIDE PKWY .31'� 9
(Description, number of 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.
Date: 1 2/20/20 19
Signature:'���- `v
1
A public entity may require a stricter and/or more extensive form of certification.
_■;� Culifomin PUBLIC WORKS PAYROLL REPORTING FORM
il■ Dqa mmnt of
Industrial Relations
Page
1
NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO.: ADDRESS:3584
1 PWLC 11, INC. 855783 E La Campana Way, Palm Springs, CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
PAYROLL NO.: 1 FINAL FOR WEEK ENDING: 12122/2019 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ120 PLANT INSTALL EISEI'
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: WSD 5029463 PROJECT AND LOCATION:
(1)
(2) I (3)
M T W TH F S S
(7)
(E)
(9)
DATE
I
HOURLY
NAME, ADDRESS AND
j I WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
16 17 118 19 2 c 21 22
SOCIAL SECURITY NUMBER
u F CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO
OF EMPLOYEE
E I
O A
WEEK
1
9i.
HOURS WORKED EACH DAY
3 I Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
479.29
27871
Diaz Ortega, Carmelo
PROJECT
PROJECTS
TAX
(SOC.SECJ
TAX
SDI
HOLIDAY
&\\'ELF.
PENSION
33583 Navajo Tr
(Maintenance
Laborer
S
8
B
fit)
12.36
Cathedral City CA 92234
1
234.84
531.48
6.22
40.66
0.00
5.31
0.00
0.00
0.00
1
TOTAL
1
TRAINC.
FUND
DUESTPAV/
SUBS.
SAVINGS
OTHER"
DEDUC-
1
D
1
1
2
18.54
ADMIN
TIONS
1
0.00
0.00
0.00
0.00
0.00
0.00
52.19
1 ILandscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
564.30
27872
Dimas, Pedro Reyes
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
&WELF.
PENSION
31-900 Avenida El Mundo
(Maintenance
Laborer
S
6
6
16.00
152.00
664.00
Cathedral 92234
1
Clty CA
35.63
50.79
6.64
6.64
0.00
0.00
0.00
TRAVTRAINC.
TOTAL
FUND
DUES
SUBS.
SUBS.
SAVINGS
OTHER•
DEDUC-
T
1
ADMIN
TIONS
I
D
1
24.00
0.00
0.00
0.00
0.00
0.00
0.00
99.70
5 1 Landscape
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
510.64
27873
Vargas, Genaro
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
&\\'ELF.
PENSION
69130 Victoria Dr
(Maintenance
Laborer
g
8
8
16
13.00
Cathedral City CA 92234
1
247.00
559.00
0.00
42.77
0.00
5.59
0.00
0.00
0.00
1
TRAINC.
FUND
DOES
SU�V/
SAVINGS
OTHER-
TOTAL
DEDUC-
1
ADMIN
TIONS
I
0
1
1
2
19.50
0.00
0.00
0.00
0.00
0.00
0.00
48.36
1 ILandsca e
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
p
1 Maintenance
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
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S
TRAINC.
FUND
DUES
SUBS,/
SAVINGS
OTHER-
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T
ADMIN
TIONS
I
0
S=STRAIGHT LIME -OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Furor A-I-IJI (NeW ^_-SIB) O=OVERTIME wage detemrinations must be separately listed. Use extra shect(s) ifnecessary (See reverse side)
SDI =STATE DISABILITY INSURANCF-
NOTICE TO PUBLIC ENTITY
For Privacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 Kristy South
(Name — print)
Controller
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
, the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the -records or copies thereof submitted and consisting of COL0
12U PLANT INSTALL EISEN.WER/SINALOA
(Description, number of 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.
Date: 12/27/2019
G " 0, /
Signature:
A public entity may require a stricter and/or more extensive form of certification.
J■;� Calirornia PUBLIC WORKS PAYROLL REPORTING FORM
ii Deparom t or
lnduslrinl Relations
Page of
NAME OF CONTRACTOR: CONTRACTOR'S LICENSE No.: ADDRESS:
PWLC II, INC. 855783 3584 E LA CAMPANA WAY PALM SPRINGS CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
PAYROLL NO.: 1 FINAL FOR WEEK ENDING:01119/2020 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ113 MONTEREYICOLIMA
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: WSD 5029463 PROJECT AND LOCATION:
(I)
(2) 1 (3)
M I T I W TH F S S
(7)
(g)
(9)
DATE
HOURLY
NAME, ADDRESS AND
F O I WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
13 19 15 16 17 18 19
SOCIAL SECURITY NUMBER
3 10 CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO,
OF EMPLOYEE
`o P 1
o
WEEK
j I
z o
HOURS WORKED EACH DAY
1 (LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
(HEALTH
555.44
28158
DIMAS, PEDRO REYES
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
H
N
&'F.LF.
PENSION
31-900 AVENIDA EL MUNDO
(MAINTENANCE
LABORER
5
8
8
8
24
16.00
CATHEDRAL CITY CA 92234
I
I
396.00
652.00
34•05
49.87
6.12
6.52
0.00
0.00
0.00
TRAINC.
FUND
DUES
TRAM
SUBS.
SAVINGS
OTHER"
TOTAL
I
5
•5
24.00
ADMUV
TIONS
Ttons
I
D
0.00
0.00
0.00
0.00
0.00
0.00
96.56
3 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAO
HEALTH
446.30
26156
MORENO, FRANCISCO G
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
&WELF.
PENSION
17300 CORKILL #28
(MAINTENANCE
LABORER
s
8
8
3
19
14.00
266.00
490.00
1.31
37.49
0.00
4.90
0.00
0.00
0.00
DESERT HOT SPRINGS CA 92241
1
I
THAN/
TOTAL
I
TRAING.
FUND
DUES
SUBS.
OTHER-
T
ADMIN
TIONSDEDUTIOXS
I
O
0.00
0.00
0.00
0.00
0.00
0.00
43.70
5 ILANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
474.78
28159
VARGAS, GENARO
( MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
69130 VICTORIA DR
LABORER
S
8
6.5
8
22,5
13.50
CATHEDRAL CITY CA 92234
r
303.75
519.75
0.00
39.77
0.00
5.20
0.00
0.00
0.00
TRAING.
FUND
DUES
RAY/r
SUUBS.
SAVINGS
OTHER•
TOTAL
DEDUC'-
AD MIN
T1."
I
O
I
0.00
0.00
0.00
0.00
0.00
0.00
44.97
O 1 LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VACI
HEALTH
28167
RAMIREZ RENTERIA, DIANA
(MAINTENANCE
PROJECT
PROJECTS
TAx
tsOC.SEC.)
TAX
SDI
HOLIDAY
&P'ELF.
PENSION
31190 ARBOR REAL
LABORER
1
S
8
8
14.00
112.00
560.00
THOUSAND PALMS CA 92276
25.17
42.84
7.52
5.60
0.00
0.00
0.00
I
TRAINC.
FUND
DUES
TRAY
SUBS./
SAVLNGS
OTHER •
TO AL
DEDUC-
1
ADMIN
TIONS
I
D
0.00
0.00
0.00
0.00
0.00
0.00
81.13
S =STRAIGHT TIME -OTHER- Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
hnn A-I-131 (New 2-90) O= OVERTIME wage detemlinations must be separately listed, Use extra sheet(s) if necessary (See reverse Side)
SDI = STATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 1 I inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
COLO113 MONMREY/COUMA ON EISENHOWER2 PAGES
that the records or copies thereof submitted and consisting of
(Description, number of 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.
Date: 0 1 /22/2020
Signature:
A public entity may require a stricter and/or more extensive form of certification.
CAMIColitumin PUBLIC WORKS PAYROLL REPORTING FORM
Deperu ent of
Indmirial Relatiom
Page
I NAME OFCONTRA CTOHI, PWLC II, INC. CONTRACTORS LICENSE NO.: 855783 ADDRESS:3584 E LA CAMPANA WAY PALM SPRINGS CA 92262
OR SIIBCONTRACrOR: SPECIALITY LICENSE NO.:
PAYROLL NO.: 2 FINAL FOR WEEK ENDING:01/26/2020 SELF -INSURED CERTIFICATE NO: PROJECT OR CONTRACT NO.:
COL0114 COLIMA/ARROBA ON
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO,: (A/SD 5029463 PROJECT AND LOCATION:
(I)
(2) 1 (3)
M I T I W TH I F I S I S
(7)
(8)
(9)
DAB
1
HOURLY
NAME, ADDRESS AND
ri 1 WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
20 21 22 23 29 25 2 fi
SOCIAL SECURITY NUMBER
s )7 F CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO,
OF EMPLOYEE
o oJ 1
WEEK
HOURS WORKED EACH DAY
ap
1 I LANDSCAPE
THIS
ALL
FED.
PICA
STATE
VAC/
HEALTH
447.80
28193
DIMAS, PEDRO REYES
MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SE
TAX
S°I
it
& WELF.
PENSION
31-900 AVENIDA EL MUNDO
(
LABORER
s
7.5
8
8
8
31.5
16.00
CATHEDRAL CITY CA 92234
1
516.00
516.00
20.45
39.47
3.12
5.16
0.00
0.00
0.00
TRAM/
TOTAL
I
TRAINC.
FUND
DUES
SUBS.
SAVINGS
OTHER-
DEDOC-
1
.5
24.00
ADMLN
TiONS
0
5
I
0.00
0.00
0.00
0.00
0.00
0.00
68.20
3 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
409.24
28191
MORENO, FRANCISCO G
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
5DT
HOLIDAY
&WELF.
PENSION
17300 CORKILL #28
IMAINTENANCE
LABORER
S
8
8
8
24
14.00
DESERT HOT SPRINGS CA 92241
1
I
336.00
448.00
0.00
34.28
0.00
4.48
0.00
0.00
0.00
TRAY/
TOTAL
1
TRAING.
FUND
DUES
SUBS.
SAVINGS
OTHER'
DEDUC-
T
ADMIN
T70NS
TJONS
O
I
0.00
0.00
0.00
0.00
0.00
0.00
38.76
5 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
REALTH
403.89
28195
VARGAS,GENARO
(MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
&WELF.
PENSION69130
VICTORIA DR
LABORER
1
S
8
8
8
8
32
13.50
442A3
442.13
CATHEDRAL CITY CA 92234
0.00
33.82
0.00
4.42
0.00
0.00
0.00
1
TRAINC.
DUES
THAN'/
SUBS.
SAVINGS
OTHER"
TOTAL
DEDUC-
I
AIND
jl)-
O
.5
.5
20.25
0.00
0.00
0.00
0.00
0.00
0.00
38.24
fj 1 LANDSCAPE
TIII$
ALL
FED.
FICA
SrATF.
SIFT
\'AC/
HEALTH
pF.NS10N
402.12
28203
RAMIREZ RENTERIA, DIANA
I MAINTENANCE
PROJECT
PROJECTS
T
Boc, sec.)
TAX
no
& NTLF.
31190 ARBOR REAL
LABORER
1
S
8
8
16
14.00
234.50
458.50
THOUSAND PALMS CA 92276
12.99
35.08
3.72
4.59
0.00
0.00
0.00
1
TRAFNG.
FUND
DUES
SUes./
SAVINGS
OTHER'
TOTAL
DEDUC-
T
kDMIN
TfONS
5
.5
21.00
0.00
0.00
0,00
0.00
0.00
0.00
56.38
1
0
S =STRAIGHT TIME 'OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Form A-I-131 (New 2-00) O=OVERTIME wage determinations must be separately listed. Use extra shect(s) iFnecessary (See reverse side)
SDI = SrAI F. DISAHILITY INSURANCE
r�
Californio
Dcpurtmcnl of
CiR [ndasMnl Relations
PUBLIC WORKS PAYROLL REPORTING FORM
Page of
1
NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO.: ADDRESS:
I PWLC II, INC. 855783 3584 E LA CAMPANA WAY PALM SPRINGS CA 92083
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
1 PAYROLL NO.:2 FINAL FOR WEEK ENDING: 01/26/2020 SELF -INSURED CERTIFICATE NO,: PROJECT OR CONTRACT NO.:
COLQ114 COLIMA/ARROBA ON
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: WSD 5039463 PROJECT AND LOCATION:
(1)
(2) 1 (3)
M I T I W TH I F I S I S
(8)
(9)
HOURLY(7)
NAME, ADDRESS AND
WORK
DATE
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
20 21 22 23 2 9 25 2 6
SOCIAL SECURITY NUMBER
3 u CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
OFEMPLOYEE
c o
WEEK
HOURS WORKL•D EACH DAY
d o
zx•
0 (LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
28194
VALDEZ CISNEROS, SALVADOR
MAINTENANCE
PROJECT
PROJECTS
TAX
(sOC. SEC.)
TAX
s"1
HOLIDAY
& WELF.
PENSION
PENSION
12966 CACTUS DR
1
LABORER
S
8
8
8
24
15.00
DESERT HOT SPRINGS CA 92240
1
371.25
491.25
26.24
37.58
5.16
4.91
O.Oo
0.00
0.00
1
OTAL
1
TRAING.
FUND
DUES
SUB.tiTRAV/
SAVINGS
OTHER"
DEDUC-
1
5
22.50
ADMIN
TION'S
5
1
0.00
0.00
0.00
0.00
0.00
0.00
73.89
1
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
I
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
HOLIDAY
&{VELF.
S
1
TRAY/
TOTAL
1
TRAING.
FUND
DUES
SUBS,
SAVINGS
OTHER•
DEDUC
1
ADMIN
TIONR
TIONS
0
1
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
I
S
I
I
V
TOTAL
TRAING.
FUND
DUES
S�
SAVINGS
O'rHER'
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T
ADMLN
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I
O
THIS
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SDI
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HEALTH
pF.NS10N
1
PROJECT
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TA%
ISOC. SEC.)
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EIVAC Y
&P'ELF.
I
S
I
TOTAL
1
TRAING.
FUND
DUES
SUBS.
SUBS.
SAVINGS
OTHER'
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1
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THINS
T10!VS
I
0
S- STRAIGHT TIME •G n1ER-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
F—A-I-131 (New2-00) O = OVERTIME wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SDI = STATE DISABILITY INSURANCE.
c
NOTICE TO PUBLIC ENTITY
For Privacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
CO10114 COUMA/ARROBA ON EISENHOWER 3 PAGES
that the records or copies thereof submitted and consisting of
(Description, number of 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.
Date: 0 1 /27/2020
Signature:
A public entity may require a stricter and/or more extensive form of certification.
_■;� Califomia PUBLIC WORKS PAYROLL REPORTING FORM
i■ Department of
Industrial Relations
Page
1
NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO.: ADDRESS:3584
1 PWLC II, INC. 855783 E LA CAMPANA WAY PALM SPRINGS CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
PAYROLL NO.:1 FOR WEEK ENDING:01/19/2020 SELF -INSURED CERTIFICATE NO.; PROJECTOR CONTRACT NO.:
COLO114 COLIMA/ARROBA ON
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: yySD 5029463 PROJECT AND LOCATION:
(I)
(2) 1 (3)
M T W TH F S S
(7)
(5)
(9)
DATE
HOURLY
NAME, ADDRESS AND
�x I WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
13 19 15 1 16 17 18 19
SOCIAL SECURITY NUMBER
s u P CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
OF EMPLOYEE
o c
WEEK
I
z
HOURS WORKED EACH DAY
1 I LANDSCAPE
THIS
ALL
FEB.
FICA
STATE
VAC
HEALTH
555.44
28158
DIMAS, PEDRO REYES
MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
31-900 AVENIDA EL MUNDO
LABORER
S
8
8
16.00
CATHEDRAL CITY CA 92234
I
128.D0
652.00
34.05
49.87
6.12
6.52
0.00
0.00
0.00
TRAY
TOTAL
1
TRAINC.
FUND
DUES
SUBS!
SAVINGS
OTHER"
DEDUC-
T
ADMLN
•PIONS
I
O
0.00
0.00
0.00
0.00
0.DO
0.00
96.56
3 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
PAC/
HEALTH
446.30
28156
MORENO, FRANCISCO G
MAINTENANCE
PROJECT
PROJECTS
TAX
ISOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
pF.NSION
17300 CORKILL #28
I
LABORER
S
6
8
14.00
112.00
490.00
1.31
37.49
0.00
4.90
0.00
0.00
0.00
DESERT HOT SPRINGS CA 92241
1
1
TRAVI
TOTAL
1
TRAWL.
FUND
DUES
SUBS.
SAVINGS
OTHER`
DEDUC-
T
ADMIN
TIONS
I
O
0.00
0.00
0.00
0.00
0.00
0.00
43.70
5 ILANDSCAPE
THIS
ALL
FED.
FICA
STATE
VACI
DEALTII
474.78
28159
VARGAS,GENARO
PROJECT
PROJECTS
TAX
(SOC.SF.C.)
TAT
SDI
HOLIDAY
&{PELF.
PENSION
69130 VICTORIA DR
(MAINTENANCE
LABORER
S
8
8
13.50
CATHEDRAL CITY CA 92234
1
108.00
519.75
0.00
39.77
0.00
5.20
0.00
0.00
0.00
1
1
TRAINC.
FUND
DUES
SUUBB.9V)
SAVINGS
OTHER"
DED C-
ADMI-N
TIONS
r
D
0.00
0.00
0.00
0.00
0.00
0.00
44.97
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
1
PROJECT
PROJECTS
TAX
(SOC. Sec.)
TAX
SDI
HOLIDAY
& p'ELF.
PENSION
r
5
I
TOTAL
TAAWC.
FUND
DUES
SUUBSVI
SAVINGS
OTHER*
DEDUC-
T
ADNIIN
TIONS
r
O
s=S'fRAICHT" 1'IME "OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Farm A-1-u 1 IN— +-ao) D= OVERTIME wage determinations must be separately listed. Use extra shect(s) if necessary (See reverse side)
SDI = STATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privaev Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
COLO114 COLIMAPARRO&1 ON EISENHOWER2 PAGES
that the records or copies thereof submitted and consisting of
(Description, number of 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.
Date: 01 /22/2020
Signature: �j
A public entity may require a stricter and/or more extensive form of certification.
CARCulifomiu PUBLIC WORKS PAYROLL REPORTING FORM
Deportment of
Industrial Relations
Page
NAME OF CONTRACTOR: PWLC II, INC. CONTRACTOR'SLICENSENO.:
ADDRESS:
OR SUBCONTRACTOR: SPECIALITY
LICENSE NO.: 855783 3584 E LA CAMPANA WAY PALM SPRINGS CA 92262
I PAYROLLNO.:1 FINAL FOR WEEK ENDING: 02/02/2020
SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
(4) DAY (5) (G)
COL0115 ARROBA/CHILLON OIS
WORKERS'COMPENSATION POLICY NO.: VVSD 5029463 PROJECT AND LOCATION:
(1) (2) 1 (3) M T W TH F S S
(7) (8) (S)
1 DATE HOURLY
NAME, ADDRESS AND TOTAL RATE
p Z WORK
GROSS AMOUNT
SOCIAL SECURITY NUMBER zp CLASSIFICATION 27 28 29 30 31 O1 02 HOURS OFPAY
OF EMPLOYEE Wo C
NET WGS CHECK
EARNED DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS PAID FOR NO.
a
7 m ' HOURS WORKED
WEEK
v EACH DAY
DIMAS. PEDRO REYES
1 I LANDSCAPE
THIS
ALL
FED.
TAX
FICA
STATE
SDI
VAc/
HEALTII
PENSION
545.94
28306
31-900 AVENIDA EL MUNDO
1MAINTENANCE
LABORER
8
8
8
8
8
16.00
PROJECT
PROJECTS
(sOC.SEC.)
TAX
HOLIDAV
&NELF.
640.00
640.00
32.85
48.96
5.85
6.40
0.00
0.00
0.00
CATHEDRAL CITY CA 92234
I
I
s
TRAING.
FUND
DUES
SU�V/
SAVINGS
OTHER•
TOTA
DEDUC-
T
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
94.06
3 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
503.25
28304
MORENO, FRANCISCO G
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
17300 CORKILL #28
LABORER
S
8
8
8
8
8
40
14.00
560.00
560.00
8.31
42.84
0.00
5.60
0.00
0.00
0.00
DESERT HOT SPRINGS CA 92241
I
I
1
TRAJISG.
FUND
DUES
SUBS/
SAVINGS
OTHER'
TOTAL
DEDUC-
1
ADMIN
T10NS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
56.75
3 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
IIEALTII
511.56
6091
BENITEZ DERAS, RAUL
I MAINTENANCE
PROJECT
PROJECTS
TAX
(50C. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
1500 E SAN RAFAEL #12
LABORER
S
8
8
8
8
8
40
14.00
560.00
560.00
0.00
42.84
0.00
5.60
0.00
0.00
0.00
PALM SPRINGS CA 92262
I
E
TRAING.
FUND
DUES
IRAV/
SAVINGS
OTHER-
TOTAL
DEDUC-
I
An..SUBS.
TI DNS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
48.44
3 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
486.98
28320
ESPARZA PLASCENCIA, MARCELO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
&{\ELF.
PENSION
33822 SHIFTING SANDS TR #2
LABORER
S
8
8
8
8
8
40
13.50
CATHEDRAL CITY CA 92234
1
I
540.00
540.00
6.31
41.31
0.00
5.40
0.00
0.00
0.00
TRAING.
FUND
DUES
THAN'
SUBS.
SAVINGS
OTHER-
TOTAL
DEDUC-
I
_
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
53.02
S=S7RAIGHT'rimc -OTHER-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Form A-1-131 (New 2.90) 0 = OVE.RTMIE wage determinations must be separately listed. Use extra shcet(s) if necessary (See reverse Side)
SDI = STALE DISABILITY INSURANCE
CHOICalifornia PUBLIC WORKS PAYROLL REPORTING FORM
Department of
Industrial Rclalions
Page
- NAME OF CONTRACTOR: PWLC II, INC. CONTRACTOR'S LICENSE NO.: ADDRESS:
855783 3584 E LA CAMPANA WAY PALM SPRINGS CA 92083
OR SUBCONTRACTOR: SPECIALITY LICENSE NO:
I PAYROLL NO.: 1 FINAL FOR WEEK ENDING:02IO2/2020 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ115ARROBA/CHILLONOP
(4) DAY (S) (6) WORKERS' COMPENSATION POLICY N0.:1AI$D 5039463 PROJECT AND LOCATION:
(t)
(2) I (3)
M I T I W TH I F S S
(7)
(8)
(9)
D
NET WGS
CHECK
NAME, ADDRESS AND
I WORK
TOTAL
HOURLY
RATE
GROSS AMOUNT
27 2 B 29 30 31 01 02
SOCIAL SECURITY NUMBER
OF EMPLOYER
c
u .. CLASSIFICATION
I
o
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
O (�.
I
WEEK
j a
HOURS WORKED EACH DAY
1 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
vna
HEALTH
473.04
28321
GUERRERO SANCHEZ, SAUL
I MAINTENANCE
PROJECT
PROJECTS
TAX
(sOC. SEC.)
TAX
SDI
HOLIDnv
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68-200 33RD AVE #120
LABORER
s
6
B
8
B
B
40
13.50
540.00
540.00
20.25
41.31
0.00
5.40
0.00
0.00
0.00
CATHEDRAL CITY CA 92234
1
TRAINC.
FUND
DUES
TRAV
SUBS./
SAVINGS
OTHER-
TOTAL
DEDUC-
T
ADMIN
TIONS
I
D
0.00
0.00
0.00
0.00
0.00
0.00
66.96
4 I LANDSCAPE
THIS
ALL
D.
FICA
STATE
VAC/
HEALTH
493.29
28319
MARTINEZ CHAVEZ, PEDRO
(MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
&WELF.
PENSION
32570 CANYON VISTA
LABORER
g
8
8
6
8
6
40
13.50
540.00
540.00
0.00
41.31
0.00
5.40
0.00
0.00
0.00
CATHEDRAL CITY CA 92234
I
TRAINC.
FUND
DUES
SUS/
SAVINGS
OTHER`
TOTAL
DEDUC-
ADMIN
TIONS
1
G
0.00
0.00
0.00
0.00
0.00
0.00
46.71
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
I
PROJECT
PROJECTS
TAX
(SOC. SEC.)TAX
SDI
HOLIDAY
&WELF.
PENSION
I
S
1
TRAINC.
FUND
DUES
SUBS/
SAVINGS
OTHER'
TOTAL
DEDUC-
T
ADMEN
TIONS
I
0
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
PROJECT
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TAX
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SDI
HOLIDAY
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I
S
1
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TO AL
DED C-
AFUND DMIN
TIONS
I
O
S- STRAIGHT TIME •o rHER-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Form A-I-I3I(Nm2-s0) 0=OVERTIME wage determinations must be separately listed. Use extra shect(s) ifnccessary (See reverse side)
SDI = STATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL0115 AFlROakONI LLOM ON EISEkHOYdER 3 PAGU'
(Description, number of 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.
Date: 02/05/2020
Signature:
A public entity may require a stricter and/or more extensive form of certification.
l
r--
_■;� Cnllram+o PUBLIC WORKS PAYROLL REPORTING FORM
i■ Dcpmhnenl of
Industrial Relalions
Page of
i
NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO.: ADDRESS:3584
' PWLC II, INC. 855783 E LA CAMPANA WAY PALM SPRINGS CA 92262
OR SUBCONTRAC70R: SPECIALITY LICENSE NO.:
PAYROLL NO.: 1 FINAL FOR WEEK ENDING: 02/09/2020 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ121 WEED ABATE CALLE
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.; WSD 5039463 PROJECT AND LOCATION:
(1)
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(9)
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603.17
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IMATINENANCE
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Fur. A-1-131 (New2-80) O=OVERTIME wage determinations must be separately listed. Use extra shect(s) ifneecssary (Sec reverse side)
SDI = S I'A m DISABILII Y INSURANCE
NOTICE TO PUBLIC ENTITY
For Priracv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
I KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
COL0121 WEED ABATE CALLE MADRID/AVE BE, 2 PAGES
that the records or copies thereof submitted and consisting of
(Description, number of 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.
Date: 2/14/2020
Signature:
A public entity may require a stricter and/or more extensive form of certification.
CARCelifumia PUBLIC WORKS PAYROLL REPORTING FORM
Department of
Ind.1riol Rdatiore
Page
1 NAME OF CONTRACTOR: PWLC II, INC. CONTRACTOR'S LICENSE NO.: 855783 ADDRESS:
3584 E LA CAMPANA WAY PALM SPRINGS CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
I PAYROLLNO.:1 FINAL FOR WEEK ENDING: 02/09/2020 SELF -INSURED CERTIFICATE NO.; PROJECT OR CONTRACT NO.:
COLQ116 CHILLON/MADRID ON
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.; yySD 5039463 PROJECT AND LOCATION:
(0
(2) 1 (3)
M T W TH F S S
(7)
(8)
(9)
DATE
NET WGS
PAID FOR
WEEK
CHECK
NO.
NAME, ADDRESS AND
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OF EMPLOYEE
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3c7a CLASSIFICATION
c c I
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HOURLY
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2
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GUERRERO SANCHEZ, SAUL
1 I LANDSCAPE
MATINENANCE
THIS
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ALL
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FED.
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STATE
TAX
SDI
VAC
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603.17
28357
68-200 33RD AVE #120
CATHEDRAL CITY CA 92234
1 LABORER
1
S
8
5
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21
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96.e3
MORENO, FRANCISCO G
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3 ILANDSCAPE
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;
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24
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STATE
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560.00
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INTERIANO CARDONA, CARLOS J
33255 DATE PALM DR #32
CATHEDRAL CITY CA 92234
5 I LANDSCAPE
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I
S
8
8
8
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Furor A-I-131(N.. 3-80) O- OVERTIME wage determinations must be separately listed. Use extra sheet(s) ifneccssary (See reverse side)
SDI = S fNI E DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
COL0116 CHILLON/MADRID ON EISENHOWER, 2 PAGES
that the records or copies thereof submitted and consisting of.
(Description, number of 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.
Date: 2/1 7/2020
A public entity may require a stricter and/or more extensive form of certification.
4dRCalifornia PUBLIC WORKS PAYROLL REPORTING FORM
Dcparimant of
Indmiriol Relations
Page
NAME OF CONTRACTOR: PWLC II, INC. CONTRACTORS LICENSE NO.: ADDRESS:3584
855783 E LA CAMPANA WAY PALM SPRINGS CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
PAYROLL NO.:2 FINAL FOR WEEK ENDING: 02I16/2020 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COL0122 WEED ABATE 8 VACA
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: VI/SD 5039463 PROJECT AND LOCATION:
(I)
(2) (3)
M I T I W TH I F I S I S
(7)
(g)
(9)
DATE
!
HOURLY
NAME, ADDRESS AND
j ` WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
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10 11 12 1 13 14 15 16
SOCIAL SECURITY NUMBER
s '0 CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
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WEEK
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y S `
2 I LANDSCAPE
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VERA, RAFAEL M
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SDI
HOLIDAY
&
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I
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8
8
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224.00
448.00
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34.28
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4.48
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0.00
0.00
DESERT HOT SPRINGS CA 92240
1
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FUND
DUES
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t
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I
0
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44.14
3 I LANDSCAPE
THIS
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FICA
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HEALTH
503.25
28486
MORENO, FRANCISCO G
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HOLIDAY
&IIELF.
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17300 CORKILL #28
(MAINTENANCE
LABORER
S
8
8
16
14.00
224.00
560.00
8.31
42.84
0.00
5.60
0.00
0.00
0.00
DESERT HOT SPRINGS CA 92241
I
1
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I
0
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0.00
0.00
0.00
0.00
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56.75
THIS
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VAC/
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I
PROJECT
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TAX
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S
I
TRAING.
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0
THIS
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S-STRAIOHTTI.NE 'OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Furor A-1-131 (New 2-80) 0 = OVERTIME wage determinations must be separately listed. Use extra shect(s) if necessary (See reverse side)
SDI =SPATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of CO0122 WEED ABATE F VACAW LOTS, 2 PAGES
(Description, number of 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.
Date: 2/19/2020
Signature:
A public entity may require a stricter and/or more extensive form of certification.
_■;� Califamia PUBLIC WORKS PAYROLL REPORTING FORM
�■ Dcpartrmnt of
Industrial Rclaliom
Page
1
NAME OF CONTRACTOR: CONTRACTOR'S LICENSE No.: ADDRESS:3584
PWLC II, INC. 855783 E LA CAMPANA WAY PALM SPRINGS CA 92262
Olt SUBCONTRACTOR: SPECIALITY LICENSE NO
PAYROLL NO.: 1 FOR WEEK ENDING: 02/16/2020 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ122 WEED ABATE 8 VACA
(4) DAY (5) (6) WORKERS'COMPENSATION POLICY NO.: WSD 5039463 PROJECT AND LOCATION:
(1)
(2) (3)
M I T I W TH F S S
(7)
(R)
(9)
DATE
�
HOURLY
NAME, ADDRESS AND
i I WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
03 09 1 05 06 07 OB 09
SOCIAL SECURITY NUMBER
30 CLASSIFICATION
(TOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO
OF EMPLOYEE
w0 c
WEEK
I
7 0 �
HOURS WORKED EACH DAY
0 I LANDSCAPE
THIS
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FICA
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VAC/
HEALT'll
409.24
28343
DORADO, ELIAS M
PROJECT
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TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
&\PELF.
PENSION
3384E VIA ECHO
(MAINTENANCE
LABORER
S
8
8
16
14.00
CATHEDRAL CITY CA 92234
I
I
224.00
448.00
0.00
34.28
0.00
4.48
0.00
0.00
0.00
TOT
TRAINC.
FUND
DUES
SU�V/
SAVINGS
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T
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I
0
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0.00
0.00
0.00
0.00
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38.76
3 I LANDSCAPE
THIS
ALT,
FED.
FICA
STATE
VAC/
HEALTH
503.25
28341
MORENO, FRANCISCO G
MAINTENANCE
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PROJECTS
TAX
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TAX
SDI
HOLIDAY
& WELF.
PENSION
17300 CORKILL #28
I
LABORER
S
0
8
14.00
DESERT HOT SPRINGS CA 92241
1
112.00
560.00
8.31
42.84
0.00
5.60
0.00
0.00
0.00
THAWI
TOTAL
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FUND
DUES
SUBS.
SUBS,
SAVINGS
OTHER'
DEDUC-
I
ADMIN
IONS
IONS
I
D
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0.00
0.00
0.00
0.00
0.00
56.75
THIS
ALL
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FICA
STATE
VAC/
UEALTH
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TAX
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HOLIDAY
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ALL
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S= STRAIGHT TIME •OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Farm A-1-D 1 (New 2-80) 0 = OVERTIME wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SDI = STATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
COL0122 WEED ABATE B VACANT LOTS, 2 PAGES
that the records or copies thereof submitted and consisting of
(Description, number of 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.
Date: 2/14/2020
Signature:�pG
A public entity may require a stricter and/or more extensive form of certification.
4dl:lCalifornia PUBLIC WORKS PAYROLL REPORTING FORM
Departnx:nt of
IMusltiel Relalio.
Page of
NAME OF CONTRACTOR: PWLC II, INC. CONTRACTOR'S LICENSE NO-: ADDRESS:
8557B3 3584 E LA CAMPANA WAY PALM SPRINGS CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
I PAYROLL NO.:2 FINAL FOR WEEK ENDJNG:03/01 /2020 SELF -INSURED CERTIFICATE NO_: PROJECT OR CONTRACT NO.:
COLQ117 MADRID/TEMECULA C
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: W$D 5039463 PROJECT AND LOCATION:
(1)
(Z) i (3)
M I T I W TH F S S
(7)
(8)
(9)
DATE
NET WGS
CHECK
NAME, ADDRESS AND
o I WORK
TOTAL
HOURLY
RATE
GROSS AMOUNT
24 25 1 26 27 28 29 01
SOCIAL SECURITY NUMBER
%UF CLASSIFICATION
I
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO
OF EMPLOYEE
o c
WEEK
HOURS WORKED
do I
EACH DAY
0 I LANDSCAPE
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STATE
VAC/
HEALTH
424.69
28686
CHAVEZ JR., ALEJANDRO
MAINTENANCE
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PROJECTS
TAX
(SOC. SEC.)
TAX
5D1
HOLIDAY
& \PELF.
PENSION
2103 JACQUES DR
I
LABORER
g
8
8
14.00
112.00
504.00
28.07
38.56
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5.04
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0.00
0.00
PALM SPRINGS CA 92262
1
1
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SAVINGS
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1
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0.00
0.00
0.00
0.00
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79.31
1 I LANDSCAPE
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HEALTH
545.94
28662
DIMAS, PEDRO REYES
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So'
HOLIDAY
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S
8
8
16.00
128.00
640.00
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48.96
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6.40
0.00
0.00
0.00
CATHEDRAL CITY CA 92234
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I
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HEALTH
642.48
28691
VALDEZ CISNEROS, SALVADOR
I MAINTENANCE
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HOLIDAY
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12966 CACTUS DR
LABORER
S
8
8
15.00
120.00
780.00
58.54
59.67
11.51
7.80
0.00
0.00
0.00
DESERT HOT SPRINGS CA 92240
I
1
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DUES
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SURE
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I
AFUND M N
TIONS
1
0.00
0.00
0.00
0.00
0.00
0.00
137.52
E
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
628.35
28663
VERA, RAFAEL M
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
Sol
HOLIDAY
&"'ELF.
PENSION
13040 CACTUS
LABORER
S
8
8
14.00
DESERT HOT SPRINGS CA 92240
1
112.00
728.00
33.38
55.70
3.29
7.28
0.00
0.00
0.00
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FUND
DUES
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SAVINGS
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T
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TIONS
I
°
0.00
0.00
0.00
0.00
0.00
0.00
99.65
I
s= STRAIGHT TLME OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
F-A-1-131 (New 2-50) O=OVERTIME wage determinations must be separately listed. Use extra shect(s) if necessary (See reverse side)
SDI = STATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For 11rivacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
- - - - - - - - - - - - - - - - - - - - - - -
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL0117 MADRIDlfEMECULA ON EISENHOWER, 2 PAGES
(Description, number of 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.
Date: 03/04/2020
Signature:
A public entity may require a stricter and/or more extensive form of certification.
Callromia PUBLIC WORKS PAYROLL REPORTING FORM
Dcpamncnt of
JRIndustrial Relaliom
Page of
NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO.: ADDRESS:
PWLC II, INC. 855783 3584 E LA CAMPANA WAY PALM SPRINGS CA 92262
ILOR
SUBCONTRACTOR: SPECIALITY LICENSE NO
I PAYROLL NO.:1 FOR WEEK ENDING:02/23/2020 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ117 MADRID/TEMECULA (:
(4) DAY (5) (6) \VORKERS'COMPENSATION POLICY NO.: (A/$D 5039463 PROJECT AND LOCATION:
(1)
(2) 1 (3)
M I T I W TH F S S
(7)
(8)
(9)
I
HOURLY
DATE.
NAME, ADDRESS AND
i 1 WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
1T 1 B 19 20 21 22 2 3
SOCIAL SECURITY NUMBER
3 u 0 CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
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NO
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E I
oo§�J
WEEK
HOURS WORKED EACH DAY
7 = p 1
0 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
414.20
28515
CHAVEZ JR., ALEJANDRO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& R'ELF.
PENSION
2103 JACQUES DR
LABORER
S
8
8
8
8
32
14.00
PALM SPRINGS CA 92262
I
1
490.00
490.00
26.39
37.49
7.02
4.90
0.00
0.00
0.00
TRAY/
TOTAL
TRAING.
FUND
DUES
SUBS.
SAVINGS
OTHER"
DEDUC-
T
I
o
2
21.00
ADMIN
TIONS
0.00
1 0.00
0.00
1 0.00
0.00
0.00
75.80
1 ILANDSCAPE
THIS
ALL
FED.
FICA
SrATE
\'AC/
HEALTH
473.11
28517
DIMAS, PEDRO REYES
MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
31-900 AVENIDA EL MUNDO
I
LABORER
S
8
8
B
8
32
16.00
CATHEDRAL CITY CA 92234
I
I
54600
548.00
23.65
41.93
3.83
5.48
0.00
0.00
0.00
I
TRAING.
FUND
DUES
TRAV/
SUBS.
SAVINGS
OTHER"
TOTAL
DEDUC-
I
5
5
.5
1.5
24.00
ADMIN
TIONS
I
0.00
0.00
0.00
0.00
0.00
0.00
74.89
0 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VACI
HEALTH
538.33
28529
VALDEZ CISNEROS, SALVADOR
MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
5ol
HOLIDAY
& WELF.
PENSION
12966 CACTUS DR
I
LABORER
S
8
8
8
8
32
15.00
DESERT HOT SPRINGS CA 92240
1
I
525.00
645.00
42.34
49.34
8.54
6.45
0.00
0.00
0.00
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FUND
DUES
SUBSI
SAVINGS
OTHER"
TOTAL
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ADMIN
TIONS
I
O
1
1
2
22.50
0.00
0.00
0.00
0.00
0.00
0.00
106.67
1 LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VACI
HEALTH
520.31
28518
VERA, RAFAEL M
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
S°I
HOLIDAY
& WELF.
PENSION
13040 CACTUS
LABORER
1
S
8
8
B
8
32
14.00
479.50
591.50
DESERT HOT SPRINGS CA 92240
I
19.73
45.25
.29
5.92
0.00
0.00
0.00
1
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AL
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1.5
21.00
0.00
0.00
0.00
0.00
0.00
0.00
71.19
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SDI =STAFF DISABILITY INSURANCE
_■;� C.fif—io PUBLIC WORKS PAYROLL REPORTING FORM
ii Depatfient of
Indmirial Relations
Page of
NAME OF CONTRACTOR: PWLC II, INC. CONTRACTOR'S LICENSE NO.: 855783 ADDRESS:3584 E LA CAMPANA WAY PALM SPRINGS CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO:
1 rUK Wttx tNUINO:UY/Z3/2U2U
SELF-INSUREDCERTIFICATENO.: PROJECT OR CONTRACT NO:
(4) DAY (5) (6)
COLO117 MADRID(TEMECULA
WORKERS' COMPENSATION POLICY NO.: WSD 5039463 PROJECT AND LOCATION:
(1)
(2) I (3)
M T W TH F S S
(7)
(S)
(9)
DATE
NET WGS
PAID FOR
WEEK
CHECK
NO.
NAME, ADDRESS AND
SOCIAL SECURITY NUMBER
OFEMPLOYEE
I WORK
o O CLASSIFICATION
ois I
7 W
TOTAL
HOURS
HOURLY
RATE
OF PAY
GROSS AMOUNT
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
17 1 E 19 20 21 22 2 3
HOURS WORKED EACH DAY
PEREZ CINTORA, JOSE I
900 E SATURNINO RD #202
PALM SPRINGS CA 92262
D l LANDSCAPE
MAINTENANCE
I LABORER
I
S
7
7
18.00
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VAC/
HOLIDAY
HEALTH
&WELF.
PENSION
668.65
28534
153.00
747.00
0.00
57.14
13.74
7.47
0.00
0.00
0.00
I
0
1
1
27.00
TRAING.
FUND
ADMIN
DUES
SUBS/
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OTHER'
TOTAL
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TIONS
l
I
0.00
0.00
0.00
0.00
0.00
0.00
78.35
I
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDr
VAC/
HOLIDAY
HEALTH
& WELF.
PENSION
I
S
TRAING.
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ADMEN
DUES
SUBS. TRAY/
SAVINGS
OTHER'
TOTAL
TIO\SDEDUC-
J
F
0
I
THIS
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ALL
PROJECTS
FED.
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TAX
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PENSION
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S
I
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DEDUC-
TIONS
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I
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S
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S = STRAIGHT TIME •OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
F— A-1-I31 (New 2-Sa) O = OVERTIME wage determinations must be separately listed. Use extra shect(s) if necessary (See reverse side)
SDI = STATE DISABILITY INSURANCE
I
NOTICE TO PUBLIC ENTITY.'
For Privacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
COLM IV VXIMCMMECUL4 ON E]SENHMVER, d PARES
that the records or copies thereof submitted and consisting of
(Description, number of 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.
Date: 2/26/2020
Signature: zi JAal-.6
A public entity may require a stricter and/or more extensive form of certification.
_■; Colifamiu PUBLIC WORKS PAYROLL REPORTING FORM
ii Deparumnt of
Indu5lrial Relations
Page
' NAME OF CONTRACTOR: PWLC II, INC. CONTRACTORS LICENSE NO: 855783 ADDRESS:3584 E LA CAMPANA WAY PALM SPRINGS CA 92262
OR SVIRCON l RACTOR: SPECIALITY LICENSE NO.:
PAYROLL NO.: 1 FINAL FOR WEEK ENDING:03/08/2020 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ118 TEMECULA/BERMUDI
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: WSD 5039463 PROTECT AND LOCATION:
(1)
(2) 1 (3)
M T W TH F S S
I.
(7)
(E)
(9)
HOURLY
DATE
NAME, ADDRESS AND
C ' WORK
TOTAL
RATE
GROSS AMOUNT
NF.T WGS
CHECK
02 03 09 05 06 07 08
SOCIAL SECURITY NUMBER
300 CLASSIFICATION
1
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO,
OF EMPLOYEE
WO a
WEEK
HOURS
_ I
WORKED EACH DAY
0 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
466.67
28707
CHAVEZ JR., ALEJANDRO
MAINTENANCE
PROJECT
PROJECTS
TAX
(SGC.SEC.)
TAX
SDI
HOLIDAY
&P'ELF,
PENSION
2103 JACQUES DR
1 LABORER
s
8
8
8
8
8
40
14.00
560.00
560.00
34.79
42.84
10.10
5.60
0.00
0.00
0.00
PALM SPRINGS CA 92262
1
1
TRATNG.
FUND
DUES
THAW
sulks.
SAVINGS
OTHER'
TOT L
DEDUC-
1
1
ADMIN
TM-
T
O
0.00
0.00
0.00
0.00
0.00
0.00
93.33
1 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
545.94
28694
DIMAS, PEDRO REYES
MAINTENANCE
PROJECT
PROJECTS
TAX
ISOC. SEC.)
TAX
SDI
HOLIDAY
& N'ELF.
PENSION
31-900 AVENIDA EL MUNDO
I
LABORER
S
8
8
8
8
8
40
16.00
640.00
640.00
32.85
48.96
5.85
6.40
0.00
0.00
0.00
CATHEDRAL CITY CA 92234
1
I
TRAV/
TOTAL
TRAINC.
FUND
DUES
SUBS
SAVINGS
OTHER"
DEDUC-
1
ADMIN
TIONS
E
O
0.00
0.00
0.00
0.00
0.00
0.00
94.06
0 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
642.48
28708
VALDEZ CISNEROS. SALVADOR
MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
&WBLF.
PENSION
12966 CACTUS DR
I
LABORER
S
8
8
8
8
8
40
15.00
DESERT HOT SPRINGS CA 92240
1
I
600.00
780.00
58.54
59.67
11.51
7.80
0.00
0.00
0.00
I
TRATNG.
FUND
DUES
THAW
SUBS
SAVINGS
OTHER'
TOTAL
DEDUC-
1
ADMIN
TIONR
I
O
0.00
0.00
0.00 1
0.00
0.00
0.00
137.52
1 LANDSCAPE
TINS
ALL
FED.
FICA
STATE
\'AC/
HEALTH
628.36
28695
VERA,RAFAELM
(MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC.SECJ
TAX
SDI
HOLIDAY
&\VELF.
PENSION
13040 CACTUS
LABORER
S
8
8
8
8
8
40
14.00
560.00
728.00
DESERT HOT SPRINGS CA 92240
1
33.38
55.69
3.29
7.28
0.00
0.00
0.00
MINNOWi
TRAING.
FUND
DUES
SUBS.
SAVINGS
OTHER"
DEOUC-
.\UMIN
T � NF
I
O
0.00
0.00
0.00
0.00
0.00
0.00
99.64
S=STRAIGHT TIME 'OTHER- Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
F-A-1-u1 (N.w 2-80) 0= OVERTmD: wage determinations must be separately listed. Use extra sheet(s) if necessary (SLc reverse side)
SDI =STATE DISABILITY INSURANCE
NOTICE. TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of
(Description, number of 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.
Date: 03/1 1 /2020
Signature:��
A public entity may require a stricter and/or more extensive form of certification.
CANCulifomie PUBLIC WORKS PAYROLL REPORTING FORM
Deparmmnt of
Indwaial Relations
Page of
3 NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO.: ADDRESS:3584
PWLC II, INC. 855783 E LA CAMPANA WAY PALM SPRINGS CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
PAYROLL NO.: 1 FINAL FOR WEEK ENDING:05/03/2020 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ123 WEED ABATEMENT V
(- DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: WCV5504144 PROJECT AND LOCATION:
(1)
(2) 1 (3)
M T W TH F S S
(7)
(8)
(9)
DATE
I
HOURLY
NAME, ADDRESS AND
I WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
27 1 28 29 30 1 2 3
SOCIAL SECURITY NUMBER
3 u CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
OF EMPLOYEE
O C 1
WEEK
HOURS WORKED EACH DAY
j
1 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
veC1
HEALTH
493.29
29426
ALVAREZ OLVERA, MARIANO
MAINTENANCE
PROJECT
PROJECTS
TAX
(SOT, SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
81271 INDIO BLVD #38
1 LABORER
S
8
8
8
8
32
13.50
432.00
540.00
0.00
41,31
0.00
5.40
0.00
0.00
0.00
INDIO CA 92201
I
TRAING.
FUND
DUES
S �"
SAVINGS
OTHER.
:T.TAL
EDUC-
T
ADMIN
IONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
46.71
0 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
507.23
29427
CHAVEZ JR., ALEJANDRO
MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& NVELF.
PENSION
2103 JACQUES DR
I
LABORER
S
8
8
8
8
8
40
14.00
560.00
560.00
4.33
42.84
0.00
5.60
0.00
0.00
0.00
PALM SPRINGS CA 92262
I
TOTAL
TRAING.
FUND
DUES
SUBS./
SAVINGS
OTHER'
DEDUC-
ADMIN
T NS
I
D
0.00
0.00
0.00
0.00
0.00
0.00
52.77
0 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
vncv
HEALTH
537.68
29428
VALDEZ CISNEROS, SALVADOR
MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& N'ELF.
PENSION
12966 CACTUS DR
I
LABORER
g
8
6
8
8
6
40
15.00
DESERT HOT SPRINGS CA 92240
I
I
600.00
600.00
10.42
45.90
0.00
6.00
0.00
0.00
0.00
TRAING.
FUND
DUES
.RA./
SAVINGS
OTHER-
TOTAL
DEDUC-
T
ADMIN
TIONS
1
G
0.00
0.00
0.00
0.00
0.00
0.00
62.32
!
TIHS
ALL
FED.
FICA
STATE
VAC/
HEALTH
I
PROJECT
PROJECTS
TAX
(SOC. SEC,)
TAX
SDI
HOLIDAY
&WELF.
PENSION
I
S
I
TUBS/
TRAING.
FUND
DUES
SAVINGS
OTHER'
DEDUC-
j
WMIN
ONS
O
s = srRNGHTTIME 'OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Form A-1-131 (N-2-80) O=OVERTIME wage determinations must be separately listed. Use extra shect(s) if necessary (Sec reverse side)
SDI = STATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL0123 WEED ABATEMENT VACANT LOTSP Q G s
(Description, number of 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.
Date: 05/07/2020
Signature: �c_J
A public entity may require a stricter and/or more extensive form of certification.
r.
_■�� California PUBLIC WORKS PAYROLL REPORTING FORM
�i� Dcpatlmcnt of
Industrial Rclations
Page
NAME OF CONTRACTOR: CONTRACTORS LICENSE NO: ADDRESS
PWLC IIINC. 3584 E LA CAMPANA WAY PALM SPRINGS CA 92262
, 855783
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
F PAYROLL NO.:1 FINAL FOR WEEK ENDING: 09/06/2020 SELF -INSURED CERTIFICATE NO PROJECT OR CONTRACT NO:
COLQ128 PALM TREE TRIM LO"�
(4) DAY (5) (G) WORKERS' COMPENSATION POLICY NO.: VI/CV5504144 PROJECT AND LOCATION:
(I)
(2) I (3)
M T I W I TH I F 1 S 1 S
(7)
(a)
(9)
DATE
HOURLY
NAME, ADDRESS AND
F i I WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
31 01 02 03 04 05 06
SOCIAL SECURITY NUMBER
s.R CLASSIFICATION
I
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
OF EMPLOYEE
o c
WEEK
HOURS WORKED EACH DAY
z ° I
0 1 TREE
THIS
ALL
FED.
FICA
STATE
SD[
VAC/
HEALTH
PENSION
616.95
30938
CHAVEZ JR., ALEJANDRO
(MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC.SEC)
TAX
HOLIDAY
&WELF.
2103 JACQUES DR
I LABORER
S
2
2
24.32
PALM SPRINGS CA 92262
f
48.64
761.68
58.99
58.25
19.87
7.62
0.00
0.00
0.00
TRAING.
FUND
DUES
RAW S
SAVINGS
OTHER-
DEDUC-
I
j
ADTOTAL
MIN
TIONS
I
O
0.00
0.00
0.00
0.00
0.00
0.00
144.73
0 I TREE
THIS
ALL
FED.
FICA
STATE
SDI
VACI
HEALTH
PENSION
841.75
30939
HENRIQUEZ, RUBEN F
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
HOLIDAY
& WELF.
15687 PALM DR #83
LABORER
S
2
2
24.32
DESERT HOT SPRINGS CA 92240
I
48.64
1149.88
154.77
87.56
49.04
11.45
0.00
0.00
0.00
F
TRAINC-
FUND
DUES
TRAF
SUBS
SUBS
SAVINGS
OTHER•
TOTAL
DEDUADMIN
TIO SC-
1
D
0.00
0.00
0.00
0.00
0.00
5.31
308.13
4 I TREE
THIS
ALL
FED.
FICA
STATE
5D1
VACI
HEALTH
PENSION
1144.43
30940
LUNA GONZALFZ, CARLOS
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
HOLIDAY
& WELF.
66145 7TH ST
I LABORER
S
2
2
29.42
DESERT HOT SPRINGS CA 92240
I
58.84
1374.62
90.20
105.15
21.09
13.75
0.00
0.00
0.00
TRAING.
FUND
DUES
SUUBSS.
SAVINGS
OTHER'
D C-
ADMIN
UDN
I
O
0.00
0.00
0.00
0.00
0.00
0.00
230.19
0 1 TREE
THIS
ALL
A
STATE
SDI
VACI
HEALTH
PENSION
880.40
30941
VALDEZ, HUMBERTO S
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOG
H
&WELF
12966 CACTUS DR#A
I LABORER
S
2
2
24 32
DESERT HOT SPRINGS CA 92240
I
48.64
1204.24
167.89
92.12
51.79
12.04
0.00
0.00
0.00
TRAtNG.
FUND
DUES
SUUBBS'
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
I
D
0-00
0.00
0.00
0.00
0.00
0.00
323.84
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Farm A-1-UI (N-2-MI) O=OVERTIME wage determinations must be separately listed Use extra sheet(s) if necessary (See reverse side)
SDI = STA1 E DISABILITY INSURANCE
.--
_■aJ� California PUBLIC WORKS PAYROLL REPORTING FORM
�i� Dcpartnncnt or
Industrial Rclations
Page
NAME OF CONTRACTOR: PWLC II, INC. CONTRACTOR'S LICENSE NO: 855783 ADDRESS. 3584 E LA CAMPANA WAY PALM SPRINGS CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO
1 PAYROLLNO:1 FINAL FOR WEEK ENDING: 09/06/2020 SELF -INSURED CERTIFICATE NO: PROJECT OR CONTRACT NO.
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO: WCV5504144 PROJECT AND LOCATION: COLQ128 PALM TREE TRIM LO'
IM
1
(1)
(2) (1)
M T I W TH F S S
(7)
(%)
(9)
DATE
NET WGS
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WEEK
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NO
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OF EMPLOYEE
I
r z WORK
p I CLASSIFICATION
o c r
�
TOTAL
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HOURLY
RATE
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GROSS AMOUNT
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DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
31 O1 02 0 3 04 0 5 0 6
I
°z z
HOURS WORKED EACH DAY
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
0 I TREE
I MAINTENANCE
I LABORER
1
S
2
2
24.32
THIS
PROJECT
ALL
PROJECTS
TAX
(S C. SEC.)
STD
SDI
HOLIDVAC/AY
&we�
PensloN
922.13
30942
48.64
1149.88
102.93
87.96
25.36
11.50
0.00
0.00
0.00
T
TRAING.
FUND
ADMIN
DUES
sunY/
SAVINGS
OTHER'
DEDUC-
TIONS
I
0.00
0.00
0.00
0.00
0.00
0.00
227.75
I
1
THIS
PROJECT
ALL
PROJECTS
FED
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VAC/
HOLIDAY
HEALTH
&WELF.
PENSION
1
s
1
TRAINC
FUND
ADMIN
DUES
SUBS
SAVINGS SAVINGS
OTHER'
DEDUC-
TIONS
I
D
I
THIS
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ALL
PROJECTS
FED.
TAX
FICA
(SOC.SEC.)
STATE
TAX
SDI
VAC/
HOLIDAY
HEALTH
&WELR
PENSION
I
S
I
TRAINC.
FUND
MIN
DUES
SUUBSS
SAVINGS
OTHER'
DEDUC-
TIONsC-
I
0
1
THIS
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ALL
PROJECTS
FED
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VA
HOLIDAY
HEALTH
&WELR
PENSION
r
S
I
1
TRAING-
FUND
DUES
TRAV/
Sun
SAVINGS
OTHER'
TIONSTOTAL
DEDUC-
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D
—
—
I
—
L
s=SH(AIMITTIME •oTlrrR-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
F—A-1-131 (N-2-8n) O=OvrRIIMr wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SDI = STAIT: DISMILITY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING 9/6/2020
PROJECT # & LOCATION COLQ128 PALM TREE TRIM LOTS NEAR LIBRARY
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
HENRIQUEZ, RUBEN F 5.31
15687 PALM DR #83
DESERT HOT SPRINGS CA 92240
*OTHER= DENTAL INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 1 ] inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLQ128 PALM TREE TRIM d PAGES
(Description, number of 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.
Date: 09/1 1 /2020
Signature: � 4.2UZ
r
A public entity may require a stricter and/or more extensive form of certification.
,���.� Calir Inia PUBLIC WORKS PAYROLL REPORTING FORM
VDepartmnt or
Ind-16.1 Relations
Page of
NNAME OF CONTRACTOR: CONTRACTORS LICENSE NO - ADDRESS:
PWLC II, INC. 855783 3584 E LA CAMPANA WAY PALM SPRINGS CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO
I PAYROLL NO: 1 FINAL FOR WEEK ENDING: 09/27/2020 SELF-INSUR ED CERTIFICATE NO: PROJECTOR CONTRACT NO:
COLQ126 CLEAN LOT -DUNE PA
(4) DAY (5) (6) WORKERS'COMPENSATION POLICY NO, WCV5504144 PROJECT AND LOCATION1.:
�
(I)
(2) (3)
M T W TH F S S
(7)
(S)
(9)
HOURLY
DATE
NET WGS
CHECK
NAME, ADDRESS AND
F i WORK
TOTAL
RATE
GROSS AMOUNT
27. 22 23 24 25 26 27
SOCIAL SECURITY NUMBER
r' o CLASSIFICATION
'z&
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO
OF EMPLOYEE
c a < F
WEEK
i
HOURS WORKED EACH DAY
-
0 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
409.24
31242
CHAVEZ JR., ALEJANDRO
1 MAINTENANCE
PROJECT
PROJECTS
TAX
SOC.SEC.)
TAX
HOLIDAY
s WELF.
2103 JACQUES DR
I LABORER
S
8
B
14.00
PALM SPRINGS CA 92262
112.00
448.00
0.00
34.28
0.00
4.48
0.00
0.00
0.00
TRAING.
FUND
DUES
VI
SUURRS.
SAVIICS
OTHER.
DEDUC-
1
T
"MIN
TIONS
I
G
0.00
0.00
0.00
0.00
0.00
0.00
38.76
6 [LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC)
HEALTH
pension
511.56
31256
GONZALEZ BARAJAS, SALVADOR
I MAINTENANCE
PROJECT
PROJECTS
TAX
[sOc. SEC.)
TAX
HOLIDAY
6 WELF.
32652 CATHEDRAL CANYON
I LABORER
S
8
6
14.00
CATHEDRAL CITY CA 92234
I
112.00
560.00
0.00
42.84
0.00
5.60
0.00
0.00
0.00
TOTAL
TRAING.
FUND
DUES
SUBS/
SAVINGS
OTHER•
DEDUC-
T
ADMIN
TIONS
I
G
0.00
0.00
0.00
0.00
0.00
0.00
48.44
4 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
482.33
31255
MARTINEZ CHAVEZ, PEDRO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC)
TAX
SDI
HOLIDAY
s WELF.
PENSION
32570 CANYON VISTA
I LABORER
S
8
8
14.00
CATHEDRAL CITY CA 92234
I
112.00
528.00
0.00
40.39
0.00
5.28
0.00
0.00
0.00
1
TRAING.
FUND
DUES
SUUBBSS.
SAVINGS
OTHER-
DEDUC-
ADMIN
TIONS
I
0
000
0.00
0.00
0.00
0.00
0.00
45.67
6 1
THIS
ALL
FED
FICA
STATE
VAC/
HEALTH
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
lF WELF.
PENSION
I
S
I
I
TRAING.
FUND
DUES
SUUE&
SAVINGS
OTHER.
DEDUC-
E
ADMIN
TIONS
O
s = STRAIMITTIME •onirlt-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
eoa�,n-1-I11 (Ncwx-Jul) o=OVERTIME wage determinations must be separately listed- Use extra sheet(s) if necessary (See reverse side)
SDI = STAIT DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privac Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL0126 CLEAN LOT -DUNE PALMS, 2 PAGES
(Description, number of 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.
Date: 1 0/02/2020
Signature: Z Yl---�
A public entity may require a stricter and/or more extensive form of certification.
r-
�,�� Caliromia PUBLIC WORKS PAYROLL REPORTING FORM
ii■ Department of
Industrial Relations
Page
NAME OF CONTRACTOR: CONTRACTORS LICENSE NO: ADDRESS:
PWLC II, INC. 855783 3584 E LA CAMPANA WAY PALM SPRINGS CA 92262
OR SUBCONTRACTOR: SPECIALITY LICENSE NO
PAYROLL NO:1 FINAL FOR WEEK ENDING: 10/11/2020 SELF -INSURED CERTIFICATE NO.: PROIECT OR CONTRACT NO:
COLQ130 WEED ABATE ADAM9
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO: WCV5504144 PROJECTAND LOCATION:
d
(1)
(2) 1 (3)
M
T W. TH F S S
(7)
(%)
(9)
i
HOURLY
DATE
NAME, ADDRESS AND
z 1 WORK
TOTAL
RATE
GROSSAMOUNT
NET WGS
CHECK
p 5 0 6 0 7 0 B 0 9 1 0 11
SOCIAL SECURITY NUMBER
502 CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO-
OFEMPLOYEE
Wo o f.
WEEK
. 1
z o
HOURS WORKED EACH DAY
0 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
507.23
31424
CHAVEZ JR., ALEJANDRO
1 MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
2103 JACQUES DR
I LABORER
S
8
B
14.00
PALM SPRINGS CA 92262
I
112.00
560.00
4.33
42.84
0.00
5.60
0.00
0.00
0.00
TRAING.
FUND
DUES
STUBS
SAVINGS
OTHER-
DEDUC-
T
ADMIN
TIONS
I
o
0.00
0.00
0.00
0.00
0.00
0.00
52.77
6 I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
511.56
31437
GONZALEZ BARAJAS, SALVADOR
1 MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
HOLIDAY
& WELF.
32652 CATHEDRAL CANYON
I LABORER
S
8
8
14.00
CATHEDRAL CITY CA 92234
I
112.00
560.00
0.00
42.84
0.00
5.60
0.00
0.00 '
0.00
TRAING
FUND
DUES
Sl1RS./
SAVINGS
OTHER-
TOTAL
DEDUC-
1
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
48.44
THIS
ALL
FED
FICA
STATE
VAC/
HEALTH
I
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
I
S
I
TOTUC-
TRAING.
FUND
DUES
SU�V/
SAVINGS
OTHER'
ADMIN
.IONS
�
O
6 1
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
1
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
&WELF.
PENSION
I
S
'
TRAWI
TRAING-
FUND
DUES
SUURS.
IN SAVGS
OTHER-
DEDUC-
ADMIN
TIONS
r
O
S = S'11WG I rr TI Mr. - nIER-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Fame A-1-131 (N-2-M) O=OVERTIME wage determinations must be separately listed- Use extra sheet(s) if necessary (See reverse side)
SDI = S 1'A'D: DISADILI'rY INSIIMNCE
NOTICE TO PUBLIC ENTITY
I'ur Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLQ130 WEED ABATE, 2 PAGES
(Description, number of 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.
Date. 1 0/1 6/2020
Signature:
A public entity may require a stricter and/or more extensive form of certification.
l
J;mlCalifornia PUBLIC WORKS PAYROLL REPORTING FORM
Department of
Industrial Relations
Page
NAME OF CONTRACTOR; CONTRACTORS LICENSE NO.: ADDRESS:
} OR SVBCONTRA(.'MR. PWLC II, INC. SPECIALITY LICENSE NO.: 855783 PO BOX 848 THOUSAND PALMS CA 92276
PAYROLL NO.:1 F I IV q Z— FOR WEEK ENDING: 11/15/20 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLA 129 TREE REMOVAL AVE
(4) DAY (5) (6) WORKL•RS' COMPENSATION POLICY NO.: WCV5504144 PROJECT AND LOCATION:
(I)
(2) 1 (3)
M T III TH F S S
(7)
(8)
(9)
NAME, ADDRESS AND
SOCIAL SECURITY NUMBER
OF EMPLOYEE
T
z, 1 WORK
uG CLASSIFICATION
o o i I
6'6
d o. l
TOTAL
HOURS
HOURLY
RATE
OF PAY
GROSS AMOUNT
EARNED
DEDUCTIONS. CONTRIBLMONS AND PAYMENTS
DATE
NET WGS
PAID FOR
WEEK
CHECK
NO
09 10 11 12 13 19 15
HOURS WORKED EACH DAY
HENRIQUEZ, RUBEN F
15687 PALM DR #83
DESERT HOT SPRINGS, CA 92240
0 ITREE
MAINTENANCE
1 LABORER
S
3
3
24,32
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC.)
STATE.
TAX
SDI
VAC/
HOLIDAY
HEALTH
& WELF.
PENSION
605.28
31836
72 96
778.24
80.18
59.13
20.61
13.04
0
0
0
'
TRAING.
FUND
111
ADIN
DUES
TRAY/SAVINGS
SUBS.
OTHER'
TOTAL
DI'
TIONS
0
I
0
0
0
0
0
0
172.96
LUNA GONZALEZ, CARLOS
66145 7TH ST
DESERT HOT SPRINGS, CA 92240
4 ITREE
1 MAINTENANCE
LABORER
1
S
3
3
27-22
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. Sec.)
STATE
TAX
SDI
VAC/
IIOLMAV
HEALTH
& W.I.F.
PENSION
763.29
31838
81.66
871.04
31.14
66.63
1.27
8.71
0
0
0
1
TRAING.
FUND
ADMIN
DUES
S BSI
SAVINGS
OTHER'
TOTAL
DEDUC-
TONS
0
I
0
0
0
0
0
0
107.75
RAMIREZ,MARCELINO
1500 E SAN RAFAEL DR #164
PALM SPRINGS, CA 92262
4 ITREE
(MAINTENANCE
LABORER
1
S
3
3
29.42
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VAC/
HOLIDAY
HEALTH
&WELF.
PENSION
808.01
31839
88.26
941.44
36.79
70.96
2.52
23.16
0
0
0
IL-T
TRAING.
FUND
ADMIN
DUES
TRAY)
SUBS.
SAVINGS
OTHER'
TOTAL
DEDUC-
TIONS
TIONS
I
0
I
0
0
0
0
0
0
133.43
4 I
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC.)
STATE.
TAX
5D1
VACJ
HOLIDAY
HEALTH
& WELF.
PENSION
I
S
I
TRAING.
FUND
ADMIN
DUES
TRAY
SUBS.
SUBS.
SAVINGS
OTHER•
TOTAL
TIONS
TIONS
I
I
0
S = STRAIGHT TIME 'OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Farm A-1-131 (New+-Na) O = OVERTIME wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SDI - STATE DISABILITY INSURANCE
l
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1, KRISTY SOUTH
(Name — print)
CONTROLLER_
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
_, the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
COL0129 TREE REMOVAL AVE SOISAGEBRUSH � Q. E
that the records or copies thereof submitted and consisting of P 9
(Description, number of pages)
are the originals or true, fall, 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.
Date: 11 /17/2020
Signature: 'f�
A public entity may require a stricter and/or more extensive form of certification.
CANCnlifatrx
Department of
Industrial Relnlinw
PUBLIC WORKS PAYROLL REPORTING FORM
Page
iNAME OF CONTRACTOR: CONTRACTOR'S LICENSE No.: ADDRESS.PO
PWLC II, INC. 855763 BOX 848 THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
PAYROLL NO.:1 r / I y A 4- FOR WEEK ENDTNG:11/15/20 SELF -INSURED CERTIFICATE NO : PROJECTOR CONTRACT NO.:
COLQ 131 TREE REMOVALS MI!
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: WCV5504144 PROJECT AND LOCATION:
(1)
(2) 1 (3)
M T W TH F S S
(7)
(8)
(9)
I
HOURLY
NAME, ADDRESS AND
i I WORK
DATE
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
09 10 11 12 13 19 15
SOCIAL SECURITY NUMBER
o G CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO
OF EMPLOYEE
o c 1
WEEK
r
o
HOURS WORKED EACH DAY
0 ITREE
THIS
ALL
FED.
FICA
STATE
v(a
HEALTH
605.28
31836
HENRIQUEZ, RUBEN F
MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
15687 PALM DR #83
LABORER
S
8
6
14
24.32
340.48
778.24
80.18
59.13
20.61
13.04
0
0
0
DESERT HOT SPRINGS, CA 92240
1
1
TRAY/
TOTA
TRAING.
FUND
DUES
SAVINGS
OTHER •
DEDUC-
ADMIN
TIONS
1
O
0
0
0
0
0
0
4 ITREE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH763.29
31838
LUNA GONZALEZ, CARLOS
MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
IPENSION
66145 7TH ST
I
LABORER
S8
6
14
27.22361.08
871.04DESERT
31.14
66.63
1.27
8.71
0
0
HOT SPRINGS, CA 92240
�V/
TRAING.
FUND
DUES
SUBS.
SAVINGS
OTHER•
T
ADMIN
TIONS TIONS
1
0
0
0
0
0
0
0
107.75
4 ITREE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
808.01
31839
RAMIREZ,MARCELINO
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
&WELF.
PENSION
1500 E SAN RAFAEL DR #164
IMAINTENANCE
LABORER
g
4
8
6
18
F21.42
529.56
941.44
36.79
70.96
2.52
23.16
0
0
0
PALM SPRINGS, CA 92262
1
TOTA
TRAING.
FUND
DUES
S BS./
SAVINGS
OTHER'
DEDUC-
T
ADMIN
T..NS
I
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SDI = STATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privncv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
- - - - - - - - - - - - - - - - - - - -- - - - _ -
1, KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
COW 731 TREE REMOVALS MISC LOCATIONS Z p
that the records or copies thereof submitted and consisting of / J
(Description, number of 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.
Date: 11 /17/2020
Signature:
A public entity may require a stricter and/or more extensive form of certification.
_■;� Cahibmin PUBLIC WORKS PAYROLL REPORTING FORM
�i.■ Department of
Indu tdal Reintiow
Page
! NAME OF CONTRACTOR: PWLC II, INC. CONTRACTOR'S LICENSE NO: 855783 ADDRESS: PO BOX 848 THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
! PAYROLL NO.: 1 F IN A 4-- FOR WEEK ENDING: 11/15/20 SELF -INSURED CERTIFICATE NO: PROJECT OR CONTRACT NO:
COLA 134 TREE REMOVALS MII
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GROSS AMOUNT
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9 10 11 12 13 19 15
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HENRIQUEZ, RUBEN F
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SDI
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15687 PALM DR #83
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8
13
24.32
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0
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763.29
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LUNA GONZALEZ, CARLOS
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5
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808.01
31839
RAMIREZ, MARCELINO
MAINTENANCE
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SDI
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1500 E SAN RAFAEL DR #164
I
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5
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29.42
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SDI -STATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1, KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
— certify under penalty of perjury
q G S
that the records or copies thereof submitted and consisting of COLO 134 TREE REMOVALS MILES E OF SEELEY 2j a-
/ ✓
(Description, number of 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.
Date: 1 1 /1 7/2020
Signature: f uGL
A public entity may require a stricter and/or more extensive form of certification.
CARCalifomin PUBLIC WORKS PAYROLL REPORTING FORM
Department of
Industrial Relmiam
Page
1 NAME OF CONTRACTOR: PWLC II, INC. CONTRACTORS LICENSE NO-: 855783 ADDRESS: PO BOX 848 THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
1 PAYROLL NO.: 1 F �� FOR WEEK ENDING: 11/15/20 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO :
COLQ 135 PALM TREE TRIMMIN
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO-: WCV5504144 PROJECT AND LOCATION:
1
M T W TH F S s
(9)
(I)
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(7)
(8)
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1
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09 10 11 12 13 14 15
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605.28
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HENRIQUEZ, RUBEN F
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TAX
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TAX
SDI
HOLIDAY
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PENSION
15687 PALM DR #83
LABORER
S
2
2
24.32
48.64
778.24
DESERT HOT SPRINGS, CA 92240
80.18
59.13
20.61
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0
0
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S BS.J
SAVINGS
OTHER'
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TIONS
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172.96
1
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4 ITREE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
763.29
31838
LUNA GONZALEZ, CARLOS
MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
66145 7TH ST
I
LABORER
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2
2
27.22
54.44
871.04
DESERT HOT SPRINGS, CA 92240
1
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107.75
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THIS
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5D1
VAC/
HEALTH
PENSION
808.01
31839
RAMIREZ,MARCELINO
PROJECT
PROJECTS
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&WELF.
1500 E SAN RAFAEL DR #164
(MAINTENANCE
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2
2
29.42
58.84
941.44
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1
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SDI -STATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Pril,:iev Cousiderations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1, KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
—(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLQ.135 PALM TREE TRIMMING Z p o- j e. S
(Description, member of 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.
Date: 11 /17/2020 Signature:
A public entity may require a stricter and/or more extensive form of certification.
CeGfornia PUBLIC WORKS PAYROLL REPORTING FORM
Dcpartmmt of
WAR Industrial Relations
Page of
NAME OF CONTRACTOR: CONTRACTORS LICENSE NO.: ADDRESS.
PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO:
PAYROLL NO.: 1-1 FINAL FOR WEEK ENDING: 01131 /2021 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COL0136 EISENHOWER SINAL(
o) DAY (5) (6) WORKERS'COMPENSATION POLICY NO: WCV5504144 PROJECT AND LOCATION:
(1)
(2) I (3)
M T W TH F S S
(7)
(S)
(9)
I
HOURLY
NAME, ADDRESS AND
z I WORK
DATE
TOTAL
RATE
GROSS AMOUNT
NET WGS
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2 5 2 6 2 7 2 B 2 9 3 0 3 1
NUMBER
SOCIALOF
c, I CLASSIFICATION
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OF PAY
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DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
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NO.
EMPLOYEE
0 o 0
WEEK
d � � I
HOURS WORKED EACH DAY
I LANDSCAPE
THIS
ALL
FED.
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sm
VAa
HEALTH
PENSION
459.42
31713/6
DIMAS, PEDRO REYES
I MAINTENANCE
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PROJECTS
TAX
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TAX
It
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317
07
31-900 AVENIDA EL MUNDO
S
8
8
6
16
I LABORER
396.00
504.00
CATHEDRAL CITY CA 92234
I
0.00
38.54
O.GO
6.04
0.00
0.GO
0.00
TOTAL
I
S
1
TRAING.
FUND
ADMIN
DUES
SUDS/
SAVINGS
OTHER'
DEDUG
TIONS
I
0.00
0.00
0.00
0.00
0.00
0.00
44.58
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
348.65
32714
LIMA, CECILIO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
HOLIDAY
&WELF.
s
24
15.00
69365 VERA DR
I LABORER
0.00
29.26
0.00
4.59
0.00
0.00
0.00
CATHEDRAL CITY CA 92234
I
TRAING.
FUND
DUES
SUBS./
SAVINGS
OTHER'
TOTAL
DEDUG
1
ADMW
TIONS
O
1
22.50
1
0.00
0.00
0.00
0.DO
0.00
0.00
33.85
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAd
HEALTH
PENSION
218.76
3271516
PEREZ, VICTOR M
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
HOLIDAY
& WELF.
300
s
8
8
i6
15.00
65467 SALIDA DEL SOL PL
I LABORER
240.00
240.00
0.00
16.36
O.110
2.88
0.00
0.00
0.00
DESERT HOT SPRINGS CA 92240
I
TRAING.
FUND
DUES
SDS/
SAVINGS
OTHER'
TOTAL
D®UG
I
1
ADMIN
TI-
�
O
0.00
0.00
0.00
0.00
0.00
0.00
21.24
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
311.50
32716
VALDEZ CISNEROS, SALVADOR
LANDSCAPE
IMAINTENANCE
15.GG
PROJECT
PROJECTS
TAX
(soc.SEC.)
TAX
HOLIDAY
&WELF.
382.50
382.50
14.79
29.26
3.23
4.59
0.00
0.00
fENSION
0.00
12966 CACTUS DR
I LABORER
S
8
8
8
24
DESERT HOT SPRINGS CA 92240
1
TRAING.
FUND
DUES
T BV/
SAVINGS
OTHER'
TOTAL
DETAL
DBG
567-85-3038
I
(
ADMIN
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1
1
22.50
0.00
0.00
0.00
0.DO
0.00
19.13
71.00
I
O
S-STRAIGHT TIME oniER-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Form A-1-131 (New 2-90) 0= OVERTIME wage determinations must be separately listed. Use extra sbeet(s) if necessary (See reverse side)
SDI = STATE DISADIISTY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT# & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
1/31/2021
COLQ136 EISENHOWER SINALOA-HILDALGO
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
19.13
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of CQWIN SlNALOA-HILDALGO 3 PAGES
(Description, number of 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.
Date: 2/16/2021
Signature: AU-& �
A public entity may require a stricter and/or more extensive form of certification.
_��� Cald6mia PUBLIC WORKS PAYROLL REPORTING FORM
ii� Depunirent of
Industrial Relations
Page
NAME OF CONTRACTOR: PWLC II, INC. CONTRACTOR'S LICENSE NO: ADDRESS:
855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO,:
PAYROLL NO.: 1 FIN' FOR \VEEK ENDING: 01/31/2021 SELF -INSURED CERTIFICATE NO-: PROJECTOR CONTRACT NO:
COL0136 EISENHOWER SINAL(
(a) DAY (5) (6) WORKERS'COMPGNSATION POLICY NO.: V,/CV5504144 PROJECT AND LOCATION:
(I)
(2) (7)
M T 1 11' T][ F S ti
(7)
(S)
(9)
DATE
NAME, ADDRESS AND
I
i I WORK
TOTAL
HOURLY
RATE
CROSS AMOUNT
25 26 27 28 29 30 31
SOCIAL SECURITY NUMBER
OF EMPLOYEE
sot CLASSIFICATION
I
c
HOURS
OF PAY
EARNED
DEDUCTIONS. CONTRIBUTIONS AND PAYMENTS
NET WGS
PAID FOR
CHECK
NO.
o
W {
WEEK
i s w
HOURS WORKED EACH DAY
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
393.78
32713
DIMAS, PEDRO REYES
I MAINTENANCE
PROJECT
PROJECTS
TAX
ISOC. SEC.)
TAX
SDI
HOLIDAY
&WELF.
PENSION
31-900 AVENIDA EL MUNDO
LABORER
s
8
8
6
22
18.00
396.00
432.00
0.00
33.04
0.00
5.16
0.00
0.00
0.00
CATHEDRAL CITY CA 92234
1
TR,MNG.
FUND
DUES
SUBS.
SAVINGS
OTHER•
TOT L
DEDUC-
T
ADMIN
TIONS
O
0.00
0.00
0.00
0.00
0.00
0.00
38.22
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
348.65
32714
LIMA, CECILIO
(MAINTENANCE
PROJECT
PROJECTS
TAX
ISOC.SEC.)
TAX
S01
SDI
&WF.LF.
PENSION
69365 VERA DR
LABORER
S
8
8
8
24
15.00
382.50
382.50
0.00
29.26
0.00
4.59
0.00
0.00
0.00
CATHEDRAL CITY CA 92234
I
TRAING.
FUND
DUES
TRAY/
SUBS.
SAVINGS
OTHER-
TOTAL
DEDUC-
I
1
22.50
ADMIN
TION.S
O
1
0.00
0.00
0.00
0.00
0.00
0.00
33.85
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
218.76
3271516
PEREZ, VICTOR M
I MAINTENANCE
PROJECT
PROJECTS
rnx
(SOC. SEC.)
TAX
SDI
HOLIDAY
& \YELP.
PENSION
300
65467 SALIDA DEL SOL PL
LABORER
s
8
8
16
15.00
240.00
240.00
0.00
18.36
0.00
2.88
0.00
0.00
0.00
DESERT HOT SPRINGS CA 92240
I
I
TRAINC.
FUND
DUES
TRAY
SUBS,
SAVINGS
OTHER-
DEDUC-
I
ADMIN
ADMIN
TIONS
I
O
-
I
0.00
0.00
0.00
0.00
0.00
0.00
21.24
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VA
HEALTH
311.50
32716
VALDEZ CISNEROS, SALVADOR
I MAINTENANCE
PROJECT
PROJECTS
TAX
tSOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSFON
12966 CACTUS DR
LABORER
s
8
B
8
24
15.00
382.50
382.50
14.79
29.26
3.23
4.59
0.00
0.00
0.00
DESERT HOT SPRINGS CA 92240
I
I
TRAING.
FUND
DUES
TRAY/
SUBS.
SAVINGS
OTHER-
TOTAL
➢EDUC-
1
22.50
ADMIN
TIONS
O
1
0.00
0.00
0.00
0.00
0.00
19.13
71.00
I
S= STRAIGHT TIAIF 'OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
F.-A-1-131 (N-2-sa) O=OVERTIME Wage determinations most be separately listed. Use extra shect(s) if accessary (Sec reverse side)
SDI = STATE DISABILITY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
1/31/2021
COLQ136 EISENHOWER SINALOA-HILDALGO
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
19.13
NOTICE TO PUBLIC ENTITY
For Privucv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLp136 SiNALOA-HILDALGO 3 PAGES
(Description, number of 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.
Date: 2/5/2021
Signature:
A public entity may require a stricter and/or more extensive form of certification.
Clilumia PUBLIC WORKS PAYROLL REPORTING FORM
D:panmcnt of
Industrial Relations
Page
iNAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO.: ADDRESS:72350
PWLC II, INC. 855783 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
PAYROLL NO•:1 FINAL FOR WEEK ENDING:02/07/2021 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO-:
COLQ137 EISENHOWER HILDA].
(4) DAY (5) (6) WORKERS'COMPENSATION POLICY NO,:WCV5504144 PROJECT AND LOCATION:
DATE
i
HOURLY
NAME, ADDRESS AND
F i 1 WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
D1 02 03 09 05 06 07
SOCIAL SECURITY NUMBER
CLASSIFICATION
sz4
HOURS
OF PAY
EARNED
DEDUCTIONS. CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
Y N
I
c c
WEEK
I
i i
HOURS WORKED EACH DAY
LANDSCAPE
TIIIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
652.89
32742
DIMAS, PEDRO REYES
MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC.SF.CJ
T'AX
SDI
BOLIDAY
& WELF.
PENSION
31-900 AVENIDA EL MUNDO
1 LABORER
S
6
8
8
24
18.00
432.00
720,00
3.25
55.09
.13
8.64
0.00
0.00
0.00
CATHEDRAL CITY CA 92234
1
1
AV/BS-
TO AL
7BAU G.
FUND
DUES
5
SAVINGS
OTHEN•
DEDUC-
ADMIN
TIOWS
O
0.00
0.00
0.00
0.00
0.00
0.00
67.11
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE.
VAC/
HEALTH
546.89
32743
LIMA, CECILIO
PROJECT
PROJECTS
TAX
(sOC.SEC.)
TAX
SDI
HOLIDAY
&WELF.
PENSION
69365 VERA DR
(MAINTENANCE
LABORER
S
8
8
8
24
15.00
CATHEDRAL CITY CA 92234
I
360.00
600.00
0.00
45.91
0.00
7.20
0.00
0.00
0.00
TRAYI
TOTAL
TR,MNG.
FUND
DUF_S
SUBS.
SUBS.
SAVINGS
OTHER'
DEDUC-
'
AUM171
TIONS
THAN.
'
O
0.00
0.00
0.00
0.00
0.00
0.00
53.11
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
546.90
6303
PEREZ, VICTOR M
MAINTENANCE
PROJECT
PROJECTS
TAX
(soc SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
65467 SALIDA DEL SOL PL
I
LABORER
S
8
8
8
24
15.00
360.00
600.00
0.00
45.90
0.00
7.20
0.00
0.00
0.00
DESERT HOT SPRINGS CA 92240
I
I RAING
FUND
DUES
TRAVI
SUBS.DEDUC-
SUBS.
SAVINGS
OTHER'
TOTAL
ADMIN
TIOW
I
0.00
0.00
0.00
0.00
0.00
0.00
53.10
LANDSCAPE
THIS
ALL
FED.
FICA
STATE,
VAC/
HEALTH
472.88
32744
VALDEZ CISNEROS, SALVADOR
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
IIOLIDAY
& W'ELr.
PENSION
12966 CACTUS DR
LABORER
S
8
8
8
24
15.00
DESERT HOT SPRINGS CA 92240
I
360.00
600.00
36.54
45.91
7.47
7.20
0.00
0.00
0.00
TOTAL
TRAING.
FUND
DUES
SUBS./
SAVINGS
OTHER-
DEDUC-
T
ADMI.N
TH1N1
O
0.00
0.00
0.00
0.00
0.00
30.00
127.12
S=STRAIGHT TIME. 'OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
rom, A-1-D1 (N-240) O=OVERTIME wage determinations must be separately listed. Use extra shect(s) if necessary (Sec reverse side)
SDI = STATE DISABILITY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING 2/7/2021
PROJECT# & LOCATION COLQ137 EISENHOWER HILDALGO-MONTEZUMA
(g)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
VALDEZ CISNEROS, SALVADOR 30.00
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
NOTICE TO PUBLIC ENTITY
For Privacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of pej a y
that the records or copies thereof submitted and consisting of COLQ137 HILDALGO-MONTEZUMA 3 PAGES
(Description, number of pages)
are the originals or true, frill, 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.
Date: 2/11 /2021
Signature: ' G z
IV
A public entity may require a stricter and/or more extensive form of certification.
CAMIGa1iJitmia PUBLIC WORKS PAYROLL REPORTING FORM
Dcpurumnt or
Industrial Rcloli-,
Page of
NAME OF CONTRACTOR: PWLC II, INC. CONTRACTOR'S LICENSE NO-: 855783 ADDRESS:72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
PAYROLL NO.:1 FINAL FOR WEEK ENDiNG:02/07/2021 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ138 EISENHOWER MONTE
(4) DAY (5) (() WORKERS' COMPENSATION POLICY NO.: WCV5504144 PROJECT AND LOCATION:
(H
(2) 1 (J)
M T W TII F S S
(7)
(S)
(9)
1
HOURLY
DATE
NAME, ADDRESS AND
y i 1 WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CIIECK
01 02 03 04 05 106 07
SOCIAL SECURITY NUMBER
s o 3 CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
OF EMPLOYEE.
o a .�- 1
WEEK
!
Z i w
HOURS WORKED EACH DAY
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VA
HEALTH
652.89
32742
DIMAS, PEDRO REYES
MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC.sEC.)
TAX
SDI
HOLIDAY
& WELF,
PENSION
31-900 AVENIDA EL MUNDO
l LABORER
a
8
8
16
18.00
288.00
720.00
3.25
55.09
.13
8.64
0.00
0.00
0.00
CATHEDRAL CITY CA 92234
I
THAW
TOTAL
TR.\ING.
FUND
UUES
SUBS.
OTHER•
DEDUC-
1
ADMIN
TIONS
1
0
0.00
0.00
0.00
0.00
0.00
0.00
67.11
(LANDSCAPE
THIS
ALL
FEB.
FICA
STATE
VAC/
IIF.ALTII
546.69
32743
LIMA, CECILIO
MAINTENANCE
PROJECT
PROJECTS
TA.X
(SOC SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
69365 VERA DR
1
LABORER
S
8
8
16
15.00
240.00
600.00
0.00
45.91
0.00
7.20
0.00
0.00
0.00
CATHEDRAL CITY CA 92234
I
1
1
TRAING.
FUND
DUF-S
SUBS./
SAVINGS
OTHER-
DEDUC-
ADMIN
TIONS
!
U
0.00
0.00
0.00
0.00
0.00
0.00
53.11
(LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
546.90
6303
PEREZ, VICTOR M
PROJECT
PROJECTS
TAX
(Soc. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
65467 SALIDA DEL SOL PL
(MAINTENANCE
LABORER
S
8
8
16
15.00
240.00
600.00
0.00
45.90
0.00
7.20
0.00
0.00
0.00
DESERT HOT SPRINGS CA 92240
!
Y
TRAY
TOTAL
1
TH.\ING.
F'UN'U
DUES
SUR.C/
SAVINGS
OTHER*
DEDUC-
ADMIN
TIUNS
!
D
0.00
0.00
0.00
0.00
0.00
0.00
53.10
1LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
OFkLTH
472.88
32744
VALDEZ CISNEROS, SALVADOR
I MAINTENANCE
PROJECT
PROJECTS
TAX
(Soc. sEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
12966 CACTUS DR
LABORER
S
8
8
16
15.00
240.00
600.00
DESERT HOT SPRINGS CA 92240
1
36.54
45.91
7.47
7.20
0.00
0.00
0.00
!
TRUING.
FUND
DUES
THAN"
SUBS.
SAVINGS
OTHER-
TOTAL
I
ADMIN
lEDUSC-
!.
o
0.00
0.00
0.00 1
0.00
0.00
30.00
127.12
S = STRAIG11T TIME •OTHER -Any other deductions, contributions and/or payments whelher or not included or required by prevailing CERTIFICATION MUST be completed
romp A-i-Di (N<w^_-sa) O=OVr:RTI%IF wage determinations must be separately listed. Use extra shecl(s) if necessary (Sec reverse side)
SDI = STATE DISABILITY INSURANCE.
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
2/7/2021
COLQ138 EISENHOWER MO NTEZU MA -TAM PICO
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
30.00
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
COLO138 MONTEZU MA -TAM PICC 3 PAGES
that the records or copies thereof submitted and consisting of
(Description, number of 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.
Date: 2/11 /2021
Signature: 4 z zj'�Z
A public entity may require a stricter and/or more extensive form of certification.
z --
,��� California PUBLIC WORKS PAYROLL REPORTING FORM
iil Dcponment of
Industrial Relations
Page
NAME OF CONTRACTOR: CONTRACTORS LICENSE NO, ADDRESS:
PWLC II, INC. 855783 72350 QUARRY TRL /tA THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE No :
PAYROLL NO:1 FINAL FOR WEEK ENDING: 02/14/2021 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ139 EISENHOWER MONTI
(4) DAY (5) (6) WORKERS'COMPENSATION POLICY NO: WCV5504144 PROJECT AND LOCATION:
(I)
(2) I (3)
M T I W TH I F I S I S
(7)
I
HOURLY
NAME, ADDRESS AND
F i 1 WORK
DATE
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
OB 0IF F.11 12 13 14
SOCIAL SECURITY NUMBER
Sc a o CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
OF EMPLOYEE
o` o
WEEK
HOURS WORKED EACH DAY
0 0 I
z�
I LANDSCAPE
THIS
ALL
FED,
FICA
STATE
SDI
VAC/
HEALTH
PENSION
577.67
32889
LIMA, CECILIO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(sOC. SEC.)
TAX
HOLIDAY
& WELF.
$
8
8
16
15.00
273.75
633.75
69365 VERA DR
1 LABORER
CATHEDRAL CITY CA 92234
0.00
48.47
0.00
7.61
0.00
0.00
0.00
1
TOTAL
1
1
1.5
22.50
TRAING
FUND
ADMIN
DUES
SUUBB.SV/
SAVINGS
OTHER'
DEDUC-
TIONS
D
1.5
1
0.00
0.00
0.00
0.00
0.00
0.00
56.08
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PFnslon
497.52
32890
VALDEZ CISNEROS, SALVADOR
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC)
TAX
HOLIDAY
& WELF.
CACTUS DR
1 LABORER
$
8
8
16
15.00
DESERT
DESERT HOT SPRINGS CA 92240
I
273.75
633.75
40.24
48.47
8.22
7.61
0.00
0.00
0.00
TRAV/
TOTAL
TRAING.
FUND
DUES
SUBS.
SAVINGS
OTHER-
1.5
22.50
ADMEN
Tlons
T NS
�
O
1.5
I
0.00
0.00
0.00
0.00
0.00
31.69
136.23
I
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
PROJECT
PROJECTS
TAX
(SGC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
I
S
1
TRAING.
FUND
DUES
TRAVI
SUES.
SUBS.
SAVINGS
OTHER'
TOTAL
DEDUC-
1
ADMIN
TIONS
TY.W
�
O
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
&WELF.
PENSION
I
$
W
TOTAL
TRAING.
FUND
DUES
SUUBBS.
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
I
o
S=S17WGIITTIME •OTIIFR-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
F.-A-I-131 (N-2-Nu) 0= OVERTIME wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SDI= STATE DISABILITY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
2/14/2021
COLQ139 EISENHOWER MONTEZU MA -TAM PICO
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
31.69
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLQ139 MONTEZUMA-50 3 PAGES
(Description, number of 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.
Date: 2/17/2021
Signature:
A public entity may require a stricter and/or more extensive form of certification.
Caliromia PUBLIC WORKS PAYROLL REPORTING FORM
Department of
Industrial Relations
Page
NAME OF CONTRACTOR: CONTRACTORS LICENSE NO: ADDRESS:
PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO:
PAYROLL NO.: 1 FINAL FOR WEEK ENDING: 02/14/2021 SELF -INSURED CERTIFICATE NO: PROJECTOR CONTRACTNO.:
COLQ140 TAMPICO EISENHOW
(4) DAY (5) (G) WORKERS' COMPENSATION POLICY NO.: WCV5504144 PROJECT AND LOCATION:
(1)
(2) r (3)
M I T W Tli I F I S 1 S
(7)
(E)
(9)
DATE
HOURLY
NAME, ADDRESS AND
z I WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
08 09 10 11 12 13 14
SOCIAL SECURITY NUMBER
3 o O CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO,
OFEMPLOYEE
I
o o
WEEK
I
Z
HOURS WORKED EACH DAY
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
652.90
32666
DIMAS, PEDRO REYES
I MAINTENANCE
24
PROJECT
PROJECTS
TAX
lsoc. sec.)
TAX
HOLIDAY
&WELF.
31-900 AVENIDA EL MUNDO
1 LABORER
S
8
8
8
18.00
CATHEDRAL CITY CA 92234
I
432.00
720.00
3.25
55.08
.13
8.64
0.00
0.00
0.00
TRAING.
FUND
DUES
SUUBBSV/
SAVINGS
OTHER-
DEDUC-
T
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
67.10
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
577.67
32889
LIMA, CECILIO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
HOLIDAY
&WELF.
69365 VERA DR
1 LABORER
S
8
8
8
24
15.00
CATHEDRAL CITY CA 92234
360.00
633.75
0.00
48.47
0.00
7.61
0.00
0.00
0.00
I
T
TRAING.
FUND
ADMIN
DUES
SUBS.
SAVINGS
OTHER-
DEDUC-
TIONS
I
D
0.00
0.00
0.00
0.00
0.00
0.00
56.08
I LANDSCAPE
THIS
ALL
FED-
FICA
STATE
SDI
VAC/
HEALTH
PENSION
497.52
32890
VALDEZ CISNEROS, SALVADOR
I MAINTENANCE
PROTECT
PROJECTS
TAX
lsoc. sec.)
TAX
IJOLIDAY
& WELF.
12966 CACTUS DR
I LABORER
5
8
8
B
24
15.00
DESERT HOT SPRINGS CA 92240
360.00
633.75
40.24
46.47
8.22
7.61
0.00
0.00
0.00
1
TOTAL
TRAING.
FUND
DUES
SUBS.
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
T
D
0.00
0.00
0.00
0.00
0.00
31.69
136.23
THIS
ALL
FED-
FICA
STATE
VAC/
HEALTH
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
r
5
TRAW
TOTAL
TRAING.
FUND
DUES
SUBS-
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
r
0
S=! IRAIOIITTIME •oTm?R-Any other deductions, contributions and/or paymems whether or not included or required by prevailing CERTIFICATION MUST be completed
F, m A-1-1J1 (N-2-M) o=ovER7YMli wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SDI = ti FAIT DISADILIT Y INSIJRANC17
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT# & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
2/14/2021
COLQ140 TAMPICO EISENHOWER-BERMUDAS
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
31.69
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of C0LQ1 Q EIS EN HOWER-BERM U11AS 3 PAGES
(Description, number of 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.
Date: 2/17/2021
Signature: �a
A public entity may require a stricter and/or more extensive form of certification.
California PUBLIC WORKS PAYROLL REPORTING FORM
Depur(ment of
Industrial Relations
Page
NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO: ADDRESS.
PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO:
I PAYROLL NO:1 FINAL FOR WEEK ENDING: 02/21/2021 SELF -INSURED CERTIFICATE NO: PROJECT OR CONTRACT NO:
COLQ141 2-TAMPICO EISENHO
- (4) DAY (5) (6) WORKERS'COMPENSATION POLICY NO: WCV5504144 PROJECT AND LOCATION: o
1
_H
(9)
(1)
(2) (3)
M T W 1 1; S S
(7)
(N)
I
HOURLY
S AND€WORK
I
DATE
TOTAL
PAY TE
GROSS
NET
CHECK
15 16 17 1E 19 20 21
SOCIAL SECURITY NUMBER
5`- u CLASSIFICATION
HOURS
OF
EAR EDIT
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
FOR
OF EMPLOYEE
o ao 1
WEEK
d o I
zx
HOURS WORKED EACH DAY
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
Pension
525.02
32917
PROJECT
PROJECTS
TAR
(SOC. SEC.)
TAX
HOLIDAY
& WELF.
DIMAS, PEDRO REYES
I MAINTENANCE
24
18.00
432.00
576.00
0.00
44.07
0.00
6.91
0.00
0.00
0.00
31-900 AVENIDA EL MUNDO
I LABORER
S
8
6
8
CATHEDRAL CITY CA 92234
I
TRA
TOTAL
I
TRAENC.
FUND
ADMEN
DUES
'DDa"
SAVINGS
OTHER-
DEDIIC-
TIONS
0.00
0.00
0.00
0.00
0.00
0.00
50.98
I
O
I LANDSCAPE
THIS
ALL
FED-
FICA
STATE
SDI
VAC/
HEALTH
PENSION
447.76
32918
PROJECT
PROJECTS
TAX
(soc. SEC.)
TAX
HOLIDAY
& WELF.
LIMA, CECILIO
I MAINTENANCE
32
15.00
491.25
491.25
0.00
37.59
0.00
5.90
0.00
0.00
0.00
69365 VERA DR
I LABORER
S
8
8
8
8
CATHEDRAL CITY CA 92234
TRAING.
FUND
DUES
SUBS
SAVINGS
OTHER-
DEDUC-
T
ADMIN
TIONS
p
5
5
22.50
!
0.00
0.00
0.00
0.00
0.00
0.00
43.49
LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PEnslon
392.46
32919
VALDEZ CISNEROS, SALVADOR
I MAINTENANCE
32
15.00
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
HOLIDAY
& WELF.
491.25
491.25
25.66
37.59
5.08
5.90
0.00
0.00
0.00
12966 CACTUS DR
I LABORER
S
8
B
8
8
DESERT HOT SPRINGS CA 92240
1
TRAV/
TOTAL
I
TRAING-
FUND
DUES
SUBS.
SAVINGS
OTHER-
DEDUC-
T
ADMEN
TIONS
p
.5
.5
22.50
I
0.00
0.00
0.00
0.00
0.00
24.56
98.79
THIS
ALL
FED
FICA
STATE
SDI
VAC/
HEALTH
PENSION
!
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
HOLIDAY
&WELF.
I
S
/
TOT L
!
TRAING.
FUND
DUES
SSUHS
SAVINGS
OTHER•
DEDUC-
T
ADMEN
TIONS
I
p
S= STRAIGIrr TIME •OTID:R-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Rmn A-1-I11 (N-2-M) 0=0VCRTmu3 wage determinations must be separately listed Use extra sheet(s) if necessary (See reverse side)
SDI = ti fAIE DISABILITY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
2/21/2021
COLQ141 2-TAMPICO EISENHOWER-BERMUDAS
(g)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
24.56
NOTICE TO PUBLIC ENTITY
For Privacv Considcralions
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
COM 1 a 1 2-MSENHdWER-sERMU DAS- S PAGES
that the records or copies thereof submitted and consisting of
(Description, number of 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.
Date: 2/24/2021
Signature:
A public entity may require a stricter and/or more extensive form of certification.
_■�� Caliromia PUBLIC WORKS PAYROLL REPORTING FORM
i� Depa tment of
Industrial Relations
Page
' NAME OF CONTRACTOR: CONTRACTORS LICENSE NO, ADDRESS.
PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO
I PAYROLL NO:1 FINAL FOR WEEK ENDING: 02/28/2021 SELF -INSURED CERTIFICATE NO: PROJECT OR CONTRACT NO:
COLQ142 -TAMPICO BERMUDA
(4) DAY (5) (() WORKERS' COMPENSATION POLICY NO.: WCV5504144 PROJECT AND LOCATION:
(I)
(2) I (3)
M T W TH F S S
(7)
T
HOURLY
NAME, ADDRESS AND
z I WORK
DATE
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
22 2 3 24 2 5 2 6 2 7 2 B
SOCIAL SECURITY NUMBER
o CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
OF EMPLOYEE
.6 I
WEEK
°z s u'1
HOURS WORKED EACH DAY
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC
HEALTH
PENSION
652.91
33065
DIMAS, PEDRO REYES
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
HOLIDAY
&WELF.
31-900 AVENIDA EL MUNDO
I LABORER
S
8
8
8
24
18.00
CATHEDRAL CITY CA 92234
432.00
720.00
3.25
55.07
.13
8.64
0.00
0.00
0.00
t
TRAING.
FUND
DUES
SUBS
SAVINGS
OTHER-
DEDUC-
I ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
67.09
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
546.91
33066
LIMA, CECILIO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC SEC.)
TAX
HOLIDAY
&WELF.
69365 VERA DR
I LABORER
S
8
8
8
24
15.00
CATHEDRAL CITY CA 92234
360.00
600.00
0.00
45.89
0.00
7.20
0.00
0.00
0.00
TRAV
TOTAL
I
TRAING.
FUND
DUES
SUBSS/
SAVINGS
OTHER-
DEDUC-
T
ADMIN
TIONS
I
O
0.00
0.00
0.00
0.00
0.00
0.00
53.09
I LANDSCAPE
THIS
ALL
FED
FICA
STATE
SDI
VAC/
HEALTH
PENSION
472.90
33067
VALDEZ CISNEROS, SALVADOR
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC.SEC)
TAX
HOLIDAY
& WELF.
12966 CACTUS DR
I LABORER
S
8
8
8
24
15.00
DESERT HOT SPRINGS CA 92240
I
360.00
600.00
36.54
45.89
7.47
7.20
0.00
0.00
0.00
TRAINC,
FUND
DUES
SUBS.
SAVINGS
OTHER-
TOTAL
DEDUC-
T
ADMIN
TIONS
I
0
I
0.00
0.00
0.00
0.00
0.00
30.00
127.10
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
PROJECT
PROJECTS
TAX
(.SOC. SEC-)
TAX
SDI
HOLIDAY
& WELF.
PENSION
I
S
TRAW1
TRAING
FUND
DUES
SUBS.
SUES.
SAVINGS
OTHER'
DEDTOTAL
C
T
ADMIN
TIONS
TIONS
E
0
S SIRA1(i1ITTIME •OTIIER-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
F. m, A-1-131 (N-2-w) O=OVERTIME wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SIX = STATE DISN)ILITY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PW LC 11, INC.
WEEK ENDING
PROJECT # & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
2/28/2021
COLQ142 TAMPICO BERMUDAS-DESERT CLUB
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
30.00
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of EOLQ142 BERM U DAS-DE SERT CLUB - 3 PAGES
(Description, number of 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.
Date: 3/1 /202
C��Z�AlfA4�
A public entity may require a stricter and/or more extensive form of certification.
4d;mlCalifomia PUBLIC WORKS PAYROLL REPORTING FORM
Department of
Industrial Relations
Page
NAME OF CONTRACTOR: ONTRACTORS LICENSE NO: ADDRESS:
1
PWLC II855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
ORSUBCONTRACTOR: , INC.. SPECIALITY LICENSE NO:
I PAYROLL NO:1 FINAL FOR WEEK ENDING: 02/28/2021 SELF -INSURED CERTIFICATE NO: PROJECTOR CONTRACT NO:
COLQ143-1-TAMPICO DESERT
(4) DAY
(5) (() WORKERS'COMPENSATION POLICY NO:BAICV5504144 PROJECT AND LOCATION:
Im
(I)
(2) I (3)
M T I W TH F S,
(7)
(S)
(9)
DATE
NET WGS
CHECK
NAME, ADDRESS AND
I
z WORK
!
HOURLYTOTAL RATE
GROSS AMOUNT
2 2 2 3 2 4 2 5 126 2 7 2 a
SOCIAL SECURITY NUMBER
5 0 CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO
OF EMPLOYEE
o A I
WEEK
HOURS WORKED EACH DAY
°z 2
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VA
HEALTH
PENSION
652.91
33065
DIMAS, PEDRO REYES
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC, SEC)
TAX
HOLIDAY
s WELF.
31-900 AVENIDA EL MUNDO
I LABORER
S
8
8
16
18.00
CATHEDRAL CITY CA 92234
288.00
720.00
3.25
55.07
.13
8.64
0.00
0.00
0.00
I
TRAINC
FUND
DUES
SUBS.
SAVINGS
OTHER'
TOTAL
DEDUC-
T
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
67.09
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
546.91
33066
LIMA, CECILIO
IMAINTENANCE
PROJECT
PROJECTS
TAX
(sOC.SEC)
TAX
HOLIDAY
@WELF.
PENSION
69365 VERA DR
I LABORER
S
8
8
16
15.00
CATHEDRAL CITY CA 92234
I
240.00
600.00
0.00
45.89
0.00
7.20
0.00
0.00
0.00
TRAING
FUND
DUES
TRAW
SUBS.
SAVINGS
OTHER'
TOTAL
DEDUC-
T
ADMIN
TIONS
I
0
I
0.00
0.00
0.00
0.00
0.00
0.00
53.09
I LANDSCAPE
THIS
ALL
D.
FICA
STATE
SDI
VAC/
HEALTH
472.90
33067
VALDEZ CISNEROS, SALVADOR
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
HOLIDAY
S WELF.
PENSION
12966 CACTUS DR
I LABORER
S
8
B
16
15.00
DESERT HOT SPRINGS CA 92240
240.00
600.00
36.54
45.89
7.47
7.20
0.00
0.00
0.00
I
TRAINC
FUND
DUES
TRAVI
SUDS.
SAVINGS
OTHER'
TOTAL
DEDUC-
T
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
30.00
127.10
I
THIS
ALL
FED.
FICA
STATE
VACI
HEALTH
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
S WELF.
PENSION
I
S
TRAING.
FUND
DUES
SUS as.
SAVINGS
OTHER'
DEDUC-
ADMIN
TIONS
0
S=STRAIGIITTIME 'OTUF.R-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
F^ten A-1-Ill (N-2-NU) O=OVrRnmr wage determinations must be separately listed Use extra sheet(s) if necessary (See reverse side)
SDI = STA1T DISABILITY INSIJRANCr
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
2/28/2021
COLQ143-1 TAMPICO DESERT CLUB-WASHINGTON
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLO ] 49-1 ➢ESERT CUM-WASHI NQTON - 3 PAt,E5
(Description, number of 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.
Date: 3/1 /202 1
Signature:
r'
A public entity may require a stricter and/or more extensive form of certification.
���� California PUBLIC WORKS PAYROLL REPORTING FORM
ii1 Dcparnnent of
Industrial Rclaliom
Page
t
NAME OF CONTRACTOR: CONTRACTORS LICENSE NO. : ADDRESS.
I PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO :
( PAYROLL NO:1 FOR WEEK ENDING: 03/07/2021 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ144 #2&3-TAMPICO DESE
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: WSD 5059867-00 PROJECT AND LOCATION:
Im
(1)
(2) f (3)
M I T I W TH I F I S I S
(7)
(S)
(v)
f
HOURLY
AND
WORK
f
DATE
TOTAL
RATE
SS UNT
GROEARNED
CHECKNETWGS
-. 02 03 04 OS 06 07
OlS
SOCIAL SECURITE. Y NUMBER
O O CLASSIFICATION
HOURS
OF PAY
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID OR
NO.
OF EMPLOYEE
oc [
WEEK
f
Z s
HOURS WORKED EACH DAY
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
663.70
33098
DIMAS, PEDRO REYES
1 MAINTENANCE
40
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
HOLIDAY
& WELF.
31-900 AVENIDA EL MUNDO
I LABORER
s
8
8
6
8
8
18.00
CATHEDRAL CITY CA 92234
733.50
733.50
4.60
56.12
.28
B.BO
0.00
0.00
0.00
1
TRAV/
TOTAL
TRAING.
FUND
DUES
SUBS.
SAVINGS
OTHER-
DEDUC-
I
.5
27.00
ADMIN
TIONS
p
.5
[
0.00
0,00
0.00
0.00
0.00
0.00
69.80
I LANDSCAPE
THIS
ALL
FED
FICA
STATE
SDI
VAC/
HEALTH
PENSION
557.14
33099
LIMA, CECILIO
IMAINTENANCE
PROJECT
PROJECTS
TAX
(sOC.SEC.)
TAX
HOLIDAY
&WELF.
69365 VERA DR
1 LABORER
S
8
8
8
B
8
40
15.00
CATHEDRAL CITY CA 92234
I
611.25
611.25
0.00
46.77
0.00
7.34
0.00
0.00
0.00
{
TRAING
FUND
DUES
SUBS
SAVINGS
OTHER-
DEDUC-
T
ADMIN
TIONS
I
0
.5
.5
22.50
000
0.00
0.00
0.00
0.00
0.00
54.11
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
pENSION
481.20
33100
VALDEZ CISNEROS, SALVADOR
I MAINTENANCE
15.00
PROJECT
PROJECTS
TAX
(SOC. SEC)
TAX
HOLIDAY
& WELF,
12966 CACTUS DR
I LABORER
S
8
8
8
8
8
40
DESERT HOT SPRINGS CA 92240
611.25
611,25
37.66
46.77
7.72
7.34
0.00
0.00
0.00
TOTAL
TRAING.
FUND
DUES
SURSV/
SAVINGS
OTHER•
DEDUC-
T
ADM IN
TV-
f
O
5
.5
22.50
0.00
0.00
0.00
0.00
0.00
30.56
130.05
I
THIS
ALL
FED
FICA
STATE
VACI
HEALTH
I
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
f
S
TRAYl
TOTAL
I
[
TRAING
FUND
ADMIN
DUES
SUBS.
SUBS.
SAVINGS
OTHER-
DEDUC-
TIONS
TIONS
I•
O
S =STRAIGHT TIME -OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
F-A-I-I3l (N-2-M) O=OVERTIME wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SDI =STATE DISA1311-D•V INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
3/7/2021
COLQ144-#2&3 TAMPICO DESERT CLUB-WASHINGTON
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
30.56
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
I
that the records or copies thereof submitted and consisting of COLO T440253 DESERT CU R-WASH MGTON -I PAGES
(Description, number of 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.
Date: 3/11/2021 Signature:
A public entity may require a stricter and/or more extensive form of certification.
C0:1 California PUBLIC WORKS PAYROLL REPORTING FORM
Department of
Industrial Relations
Page
1 NAME OF CONTRACTOR: CONTRACTORS LICENSE NO, ADDRESS:
855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
I OR SUBCONTRACTOR: PWLC II, INC. SPECIALITY LICENSE NO:
I PAYROLL NO: 2 FINAL FOR WEEK ENDING: 03/14/2021 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ144 #2&3-TAMPICO DESE
(d) DAY (5) (6) WORKERS' COMPETISATION POLICY NO : V1/SD 5059867-00 PROJECT AND LOCATION:
(1)
(2) F (3)
M T W TH F S S
(7)
(S)
(�J)
DATE
NET WGS
CHECK
NAME, ADDRESS AND
x> � WORK
TOTAL
HOURLY
RATE
GROSS AMOUNT
0 8 0 9 10 11 12 13 14
SOCIALOSECURITY F EMPLOYEE NUMBER
o o g F CLASSIFICATION
d o I
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
WEEK
NO
HOURS WORKED EACH DAY
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
I LANDSCAPE
I MAINTENANCE
I LABORER
F
S
8
8
15.00
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VACI
HOLIDAY
HEALTH
& WELF.
PENSION
472.90
33242
120.00
600.00
36.54
45.89
7.47
720
0.00
0.00
0.00
TRAING.
FUND
ADMIN
DUES
SUAS/
SAVINGS
OTHER-
TOTAL
DEDUC-
TIONS
T
D
F
000
0.00
0.00
0.00
0.00
30.00
127.10
LIMA, CECILIO
69365 VERA DR
CATHEDRAL CITY CA 92234
I LANDSCAPE
IMAINTENANCE
I LABORER
1
S
8
15.00
THIS
PROJECT
ALL
PROJECTS
FED
TAX
FICA
(sOC.SEC)
STATE
TAX
SDI
VAC/
HOLIDAY
BEALTI!
&WELF.
PENSION
546.91
33241
120.00
600.00
0-00
45.89
0.00
7.20
0.00
0.00
0.00
TRAING
FUND
ADMIN
DUES
SUBS
SAVINGS
OTHER'
DEDUC-
TIONS
T
I
O
0,00
0.00
0.00
0.00
0.00
0.00
53.09
I
I
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC.)
STATE
TAX
SDI
VAC/
HOLIDAY
HEALTH
& W ELF.
PENSION
1
S
TRAING,
FUND
"MIN
DUES
TRAVI
SUBS
SAVINGS
OTHER'
To AL
DEDUC-
TIONS
I
T
I
0
1
I
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC.SEC-)
STATE
TAX
SDI
VAC/
HOLIDAY
HEALTH
&WELF.
PENSION
I
S
F
I
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FUND
ADMUI
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VI
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TOTAL
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TIONS
F
O
s=simGlrrTIME •OTIIrR-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
F,- A-1-1.11 (Nc 2-W) 0=0VERTIME wage determinations must be separately listed Use extra sheet(s) if necessary (See reverse side)
SDI = STAIT- DISAIIILIIY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
3/14/2021
COLQ144-#2&3 TAMPICO DESERT CLUB-WASHINGTON
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
30.00
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
COLQ144 02M DESERT CLU&WASHINGTON - 3 PAGES
that the records or copies thereof submitted and consisting of
(Description, number of pages)
are the originals or true, full, and correct copies of the originals which depict the payroll record(s)
of the actual disbursements byway of cash, check, or whatever form to the individual or
individuals named.
Date. 3/16/202
Signature:2Ki�Z JA"4�
A public entity may require a stricter and/or more extensive form of certification.
4d;1 California PUBLIC WORKS PAYROLL REPORTING FORM
Department of
Industrial Relations
Page
fNAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO-: ADDRESS.
PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO
PAYROLLNO:1 FINAL FOR WEEK ENDING: 03/14/2021 SELF -INSURED CERTIFICATE NO: PROJECT OR CONTRACT NO:
COLA-#1-TREE/STUMP REMOV
(4) DAY (5) (f) WORKERS'COMPENSATION POLICY NO: WSD 5059867-00 PROJECT AND LOCATION:
(1)
(2) 1 (3)
M I T I W TH F S S
(7)
(N)
lJ)
DATE
I
HOURLY
NAME, ADDRESS AND
i I WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
08 09 10 11 12 13 14
SOCIAL SECURITY NUMBER
3 o F CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO
OFEMPLOYEE
o o I
WEEK
HOURS WORKED EACH DAY
o ° w 1
I TREE
THIS
ALL
FED.
FICA
STATE
SDI
VACI
HEALTH
PENSION
627.64
33269
HENRIQUEZ, RUBEN F
1 MAINTENANCE
8
PROJECT
PROJECTS
TAX
(sOC.SEC)
TAX
HOLIDAY
& WELF.
15687 PALM DR #83
I LABORER
S
8
24.32
DESERT HOT SPRINGS CA 92240
I
194.56
871.68
92.13
66.27
26.35
10.40
0.00
0.00
0.00
TOTAL
TRAING.
FUND
DUES
SUBSV/ I
SAVINGS
OTHER-
DEDUC-
T
ADMIN
TIONS
F
0
0.00
0.00
0.00
0.00
0.00
48.89
244.04
I TREE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
817.84
33270
LUNA GONZALEZ, CARLOS
I MAINTENANCE
PROJECT
PROJECTS
TAX
(sOC. SEC)
TAX
HOLIDAY
& WELF.
66145 7TH ST
I LABORER
S
8
8
27.22
DESERT HOT SPRINGS CA 92240
217.76
941.28
37.59
72.01
2.54
11.30
0.00
0.00
0.00
TRAY/
TOTAL
TRAING.
FUND
DUES
SUBS
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TInNS
I
G
0.00
0.00
0.00
0.00
0.00
0.00
123.44
I TREE
THIS
ALL
FED
FICA
STATE
SDI
VACI
HEALTH
PENSION
868.12
33271
RAMIREZ, MARCELINO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(sOC. SEC
TAX
HOLIDAY
& WELF.
S
8
6
29.42
1500 E SAN RAFAEL DR #164
I LABORER
235.36
1026.08
PALM SPRINGS CA 92262
45.33
77.03
4.33
12.08
0.00
0.00
0.00
1
1
TRAING.
FUND
DUES
SURE
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
1
0
0.00
0.00
0.00
0.00
0.00
19.19
157.96
1
THIS
ALL
FED
FICA
STATE
VACI
HEALTH
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAXSDI
HOLIDAY
& WELF.
PENSION
I
S
TOTAL
TRAING.
FUND
DUES
SUUM
SAVINGS
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DEDUC-
T
ADMIN
TIONS
I
0
S=STRAIGIrriimE •(YTIniR-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Fenn A-1-131 (Nm 2-@)) 0=0VE1tT1ME wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SDI = S I'A'I$ DISA]HU'rY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
3/14/2021
COLA-#1-TREE/STUMP REMOVAL AVE 54
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
HENRIQUEZ, RUBEN F 43.58 CALSAVERS ROTH IRA
15687 PALM DR #83 5.31 DENTAL INS
DESERT HOT SPRINGS CA 92240
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
3/14/2021
COLQ-#1-TREE/STUMP REMOVAL AVE 54
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
RAMIREZ, MARCELINO 13.88 HEALTH INS
1500 E SAN RAFAEL DR #164 5.31 DENTAL INS
PALM SPRINGS CA 92262
NOTICE TO PUBLIC ENTITY
For Privacy Con siderations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLC"1TREE15TJMPREMOVALAVE K 4 PAGES
(Description, number of 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.
Date: 03/1 6/2021
Signature:"
A public entity may require a stricter and/or more extensive form of certification.
�;OMCalifornia PUBLIC WORKS PAYROLL REPORTING FORM
Department of
Indivarial Relations
Page of
' NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO ADDRESS.
PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
PAYROLLNO:1 FINAL FOR WEEK ENDING: 03/14/2021 SELF -INSURED CERTIFICATE NO: PROJECT OR CONTRACT NO.:
COLA-TREE/STUMP REMOVAL
(4) DAY 0) (6) WORKERS'COMPENSATION POLICY NO: WSD 5059867-00 PROJECT AND LOCATION:
(I)
(2) (3)
M T W TH F S S
(7)
(R)
(J)
DATE
I
HOURLY
NAME, ADDRESS AND
z I WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
8 0 9 10 11 12 13 14
SOCIAL SECURITY NUMBER
3 0 ° CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
AID
PAID FOR
NO
OF EMPLOYEE
40 o FF�y I
WEEK
z°, ° fd I
HOURS WORKED EACH DAY
I TREE
THIS
ALL
FED
FICA
STATE
SDI
VACI
HEALTH
PENSION
627.64
33269
HENRIQUEZ, RUBEN F
I MAINTENANCE
10
PROJECT
PROJECTS
TAR
(SOC. SEC.)
TAX
HOLIDAY
& WELF.
15687 PALM DR #83
I LABORER
S
8
2
24.32
DESERT HOT SPRINGS CA 92240
I
243.20
871.68
92.13
66.27
26.35
10.40
0.00
0.00
0.00
TRAING.
FUND
DUES
SUBS'
SAVINGS
OTHER-
TOTAL
DEDUC-
ADMIN
TIONS
I
O
0.00
0.00
0.00
0.00
0.00
48.89
244.04
I TREE
THIS
ALL
FED.
FICA
STATE
SDI
VACI
HEALTH
PENSION
817.84
33270
LUNA GONZALEZ, CARLOS
I MAINTENANCE
PROJECT
PROJECTS
TAX
(soc. SEC.)
TAX
HOLIDAY
a WELF.
66145 7TH ST
1 LABORER
S
8
2
10
27.22
DESERT HOT SPRINGS CA 92240
I
272.20
941.28
37.59
72.01
2.54
11.30
0.00
0.00
0.00
TRAING.
FUND
DUES
SUUBBS.'
SAVINGS
OTHER'
DHDUC-
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
123.44
I TREE
THIS
ALL
FED
FICA
STATE
SDI
VAC r
HEALTH
PENSION
868.12
33271
RAMIREZ, MARCELINO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC.SEC.
TAX
HOLIDAY
&WELF.
S
8
2
10
29.42
294.20
1026.08
45.33
77.03
4.33
12.08
0.00
0.00
0.00
1500 E SAN RAFAEL #164
1 LABORER
PALM SPRINGS CA 92262
22
I
TRAING
FUND
DUES
SUBS
SAVINGS
OTHER-
DEDUC-
ADMIN
TIONS
I
D
0.00
0.00
0.00
0.00
0.00
19.19
157.96
I
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
PROJECT
PROJECTS
TAX
(SGC. SEC.)
TAX
SDI
HOLIDAY
S WELF.
PENSION
I
S
I
TOT L
TRAING.
FUND
DUES
SUBS.
SAVINGS
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DEDUC-
T
ADMIN I
TIONS
I
0
S=STMGIITTINW •OTTIMR-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
F,,an A-1-131 (N-2-MI) o=OVERTIME wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SDI = STA1E DISABILITY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
3/14/2021
COLA-MADISON-TREE/STUMP REMOVAL
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
RAMIREZ, MARCELINO 13.88 HEALTH INS
1500 E SAN RAFAEL DR #164 5.31 DENTAL INS
PALM SPRINGS CA 92262
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
3/14/2021
COLQ-MADISON-TREE/STUMP REMOVAL
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
HENRIQUEZ, RUBEN F 43.58 CALSAVERS ROTH IRA
15687 PALM DR #83 5.31 DENTAL INS
DESERT HOT SPRINGS CA 92240
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
CPLO-TREEIMMP REMOVAL MADI SON, 4 PAGES
that the records or copies thereof submitted and consisting of
(Description, number of 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.
Date: 03/16/2021
Signature:
A public entity may require a stricter and/or more extensive form of certification.
_■�� California PUBLIC WORKS PAYROLL REPORTING FORM
ii� Department of
Industrial Relations
Page of
I NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO: ADDRESS:
PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
I PAYROLLNO.: 2 FINAL FORWEEK ENDING:03/21/2021 SELF -INSURED CERTIFICATENO.: PROJECT OR CONTRACT NO:
COLQ145 #1-AVE52 EISENHOW
I
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO: VVSD 5059867-00 PROJECT AND LOCATION:
Is
(1)
(2) I (3)
M T I W TH I F I S I S
(7)
(R)
(�J)
DATE
HOURLY
NAME, ADDRESS AND
F I WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
15 16 17 1 B 1 9 2 0 21
SOCIAL SECURITY NUMBER
OF EMPLOYEE
0 o CLASSIFICATCON
T
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO
o a
WEEK
°z 1
HOURS WORKED EACH DAY
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
652.90
33273
DIMAS, PEDRO REYES
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
HOLIDAY
& WELF.
31-900 AVENIDA EL MUNDO
I LABORER
S
8
8
18.00
CATHEDRAL CITY CA 92234
144.00
720.00
3.25
55.08
.13
8.64
0.00
0.00
0.00
1
TRAING.
FUND
DUES
suns.
SAVINGS
OTHER'
DEDUC-
I
T
ADMIN
TIONS
I
0
I
0.00
0.00
0.00
0.00
0.00
0.00
67.10
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
546.90
33274
LIMA, CECILIO
1 MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
HOLIDAY
& WELF.
69365 VERA DR
I LABORER
S
8
8
15.00
CATHEDRAL CITY CA 92234
I
120,00
600.00
0.00
45.90
0.00
7.20
0.00
0.00
0.00
TRAING
FUND
DUES
TRAV/SUBS
SAVINGS
OTHER'
TOTAL
DEDUC-
J
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
53.10
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
472.89
33275
VALDEZ CISNEROS, SALVADOR
I MAINTENANCE
PROJECT
PROJECTS
TAX
ISSEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
12966 CACTUS DR
I LABORER
S
8
8
15.00
DESERT HOT SPRINGS CA 92240
I
120.00
600.00
36.54
45.90
7.47
7.20
0.00
0.00
0.00
TRAY
TOTAL
TRAING
FUND
DUES
sum/
SAVINGS
OTHER-
DEDUC-
AIN DM
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
30.00
127.11
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
PROJECT
PROJECTS
TAX
(SOC. SEC)
TAX
SDI
HOLIDAY
& WELF.
PENSION
I
S
I
I
TOTAL
TRAING.
FUND
DUES
SUBSTRAY/
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
I
0
S=STRAIGHrTIME •oTHER-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Faint A-I-131 (N-2-ND G=OVERTIME wage determinations must be separately listed Use extra sheel(s) if necessary (See reverse side)
SDI = STATE DISNIILITY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
3/21/2021
COLQ145-#1 AVE52 EISENHOWER-BERMUDAS
(g)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
30.00
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL014541-AVE52 EISENHOWER-BERMUDAS-3 PAGES
(Description, number of 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.
Date: 3/23/2021
Signature:
A public entity may require a stricter and/or more extensive form of certification.
,■;� California PUBLIC WORKS PAYROLL REPORTING FORM
�■ Department of
Industrial Relations
Page
'NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO: ADDRESS-
. 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
PWLC IIINC. 855783
OR
OR SUBCONTRACTOR: SPECIALITY LICENSE NO
1 PAYROLL NO,:1 FOR WEEK ENDING: 03/14/2021 SELF -INSURED CERTIFICATE NO.: PROJECTOR CONTRACT NO:
COLO145 #1-AVE52 EISENHOW�
(4) DAY (i) ((,) WORKERS' COMPENSATION POLICY NO: 1rySD 5059867-00 PROJECT AND LOCATION:
(I)
(2) I (3)
M I T I W TH F S S
(7)
(S)
('D)
DATE
NET
CHECK
NAME, ADDRESS AND
z, WORK
I
TOTAL
HOURLY
RATE
GROSSAMOUNT
0 8 0 9 10 11 12 13 14
SOCIAL SECURITY NUMBER
5 0 CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID
PAID FOR
NO.
OF EMPLOYEE
0.
WEEK
HOURS WORKED EACH DAY
z ° I
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VACI
HEALTH
PENSION
652.90
33240
DIMAS, PEDRO REYES
1 MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
HOLIDAY
6 WELF.
31-900 AVENIDA EL MUNDO
I LABORER
S
8
8
8
24
18.00
CATHEDRAL CITY CA 92234
432.00
720.00
3.25
55.08
.13
8.64
0.00
0.00
0.00
�
TRAING
FUND
DUES
SUBSI
SAVINGS
OTHER-
TOTAL
DEDUC-
ADMIN
TIONS
1
O
0.00
0.00
0.00
0.00
0.00
0.00
67.10
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
vAC/
VACI
HEALTH
546.91
33241
LIMA, CECILIO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(sOC. SEC.)
TAX
SDI
H
a WELF.
PENSION
69365 VERA DR
I LABORER
S
8
8
8
8
32
15.00
CATHEDRAL CITY CA 92234
480.00
600.00
0.00
45.89
0.00
7.20
0.00
0.00
0.00
I
TRAING
FUND
DUES
I
sum
SAVINGS
OTHER-
TOTAL
DEDUC-
ADMINI
TIONS
I
0
I
0.00
0.00
0.00
0.00
0.00
0.00
53.09
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
472.90
33242
VALDEZ CISNEROS, SALVADOR
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
IiOLmAY
et WELF.
PENSION
12966 CACTUS DR
I LABORER
S
8
8
8
8
32
15.00
DESERT HOT SPRINGS CA 92240
480.00
600.00
36.54
45.89
7.47
7.20
0.00
0.00
0.00
1
TRAUVG.
FUND
DUES
TRAY
SUBS.
SAVINGS
OTHER-
TOT L
DEDUC-
!
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
30.00
127.10
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
PROTECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
5 WELF.
PENSION
I
S
f
TOTAL
I
TRAING
FUND
DUES
SUBS.
SAVINGS
OTHER-
DEDUC-
ADMIN
TIONS
O
i
S=SnwtaITTIME •(YTIIER-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
R-A-1-131 (N-2-.)) o=Ovr_RTIMr wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SDI = STA'Ir DINADILITY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
3/14/2021
COLQ145-#1 AVE52 EISENHOWER-BERMUDAS
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
30.00
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL014541-AVE52 EISENHOWER-BERMDDAS-3 PAGES
(Description, number of 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.
Date: 3/16/2021
Signature:
A public entity may require a stricter and/or more extensive form of certification.
_■�� California PUBLIC WORKS PAYROLL REPORTING FORM
ii� Dcpnnment of
Industrial Rclatioas
Page of
NAME OF CONTRACTOR: CONTRACTORS LICENSE NO: ADDRESS:
PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO :
PAYROLL NO: 1 FOR WEEK ENDING: 03/14/2021 SELF -INSURED CERTIFICATE NO : PROJECT OR CONTRACT NO:
COLQ-#2-TREE/STUMP REMOV
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: VI/SD 5059867-00 PROJECT AND LOCATION:
�
(1)
(2) (3)
M T W TH F S S
(7)
(S)
(9)
DATE
IS
HOURLY
nAND
CDUR
F WORK
I
TOTAL
RATE
GROSS AMOUNT
NETWGS
CHECK
OB 09 10 11 12 13 14
EE.
SOCIALS TEY NUMBER
3 u CLASSIFICATION
HOURS
OF PAY
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO
OF EMPLOYEE
00 1
WEEK
°
w I
y =
HOURS WORKED EACH DAY
I TREE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
627.64
33269
HENRIQUEZ, RUBEN F
1 MAINTENANCE
li
PROJECT
PROJECTS
TAX
(.soC SEC.)
TAX
HOLIDAY
& WELF.
15687 PALM DR 83
I LABORER
s
6
24.32
DESERT
DESERT HOT SPRINGS
RINGS CA 92240
145.92
871.68
92.13
66.27
26.35
10.40
0.00
0.00
0.00
TRAINC
FUNTOTA
D
DUES
SUBSV/
SAVINGS
OTHER'
DEDUC-
ADMIN
TIONS
I
o
0.00
0.00
0.00
0.00
0.00
48.89
244.04
[TREE
THIS
ALL
FED.
F[CA
STATE
SDI
VAC/
HEALTH
PENSION
817.84
33270
LUNA GONZALEZ, CARLOS
I MAINTENANCE
PROJECT
PROJECTS
TAX
(soc.sEC)
TAX
HOLIDAY
&wELR.
ST
1 LABORER
S
6
6
27.22
T H
DESERT HOT SPRINGS CA 92240•
DESERT
I
163.32
941.28
37.59
72.01
2.S4
11.30
0.00
0.00
0.00
TKAING.
FUND
DUES
TRAV
SUBS.
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
I
O
0.00
0.00
0.00
0.00
0.00
0.00
123.44
I TREE
THIS
ALL
FED.
FICA
STATE
SDI
VACJ
HEALTH
PENSION
868.12
33271
RAMIREZ, MARCELINO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
HOLIDAY
&WELF
1500 E SAN RAFAEL DR #164
I LABORER
S
6
6
29.42
PALM SPRINGS CA 92262
I
1
176.52
1026.08
45.33
77.03
4.33
12.08
0.00
0.00
0.00
TRAING.
FUND
DUES
RAW
SUBS.
SAVINGS
OTHER-
TOTA
DEDUC-
T
ADMIN
TIONS
I
O
0.00
0.00
0.00
0.00
0.00
19.19
157.96
F
1
1 1
_ _
I
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
1
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
I
S
I
TRAING
FUND
DUES
SUBS.
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
I
0
S=SIRMG1rr1IME •o'r11ER-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
F-A-l-Ill (Ncw'---M) o= 0WIC11ME wage determinations must be separately listed Use extra sheel(s) if necessary (See reverse side)
SDI = STATE DISABILITY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
3/14/2021
COLA-#2-TREE/STUMP REMOVAL AVE 54
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
HENRIQUEZ, RUBEN F 43.58 CALSAVERS ROTH IRA
15687 PALM DR #83 5.31 DENTAL INS
DESERT HOT SPRINGS CA 92240
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
3/14/2021
COLA-#2-TREE/STUMP REMOVAL AVE 54
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
RAMIREZ, MARCELINO 13.88 HEALTH INS
1500 E SAN RAFAEL DR #164 5.31 DENTAL INS
PALM SPRINGS CA 92262
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x I inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLD-42-TREEISTUMP REMOVAL AVE 54,4 PAGES
(Description, number of 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.
Date: 03/1 6/2021
Signature:
A public entity may require a stricter and/or more extensive form of certification.
I
1
Califomiu
PUBLIC
WORKS
PAYROLL REPORTING
1 Cal
Zu'silmoat Ial
FORM
Indusuial Relations
1 4
Page of
NAME OF CONTRACTOR:
PWLC
II, INC.
CONTRACTORS
LICENSE NO :
ADDRESS:
OR SUBCONTRACTOR:
SPECIALITY
LICENSE NO
855783
72350
QUARRY
TRL #A
THOUSAND PALMS CA 92276
1 PAYROLLNO: 2 FINAL
FORWEEK ENDING:
03/21/2021
SELF -INSURED CERTIFICATE NO.:
PROJECT OR CONTRACTNO:
(q)
DAY
(5)
(()
WORKERS' COMPENSATION POLICY NO: WSD 5059867-00
PROJECT AND LOCATION:
COLQ�12-TREEISTUMP REMOV
0
(l)
(2) (3)
1
M
T W TH F S S
(7)
(S)
(9)
DATE
NAME, ADDRESS AND
I WORK
TOTAL
HOURLY
RATE
GROSS AMOUNT
15
L. fi 17 1 B 19 2 0 21
SOCIAL SECURITY NUMBER
OF EMPLOYEE
p 9 CLASSIFICATION
5 �-
I
a
HOURS
OF PAY
EARNED
DEDUCTIONS,
CONTRIBUTIONS AND PAYMENTS
CHECK
NO.
o
� r
LPATDFOR
z °x w
HOURS WORKED EACH DAY
HENRIQUEZ, RUBEN F
TREE
1 MAINTENANCE
THIS ALL
PROJECT PROJECTS
FED
TAX
FICA
(sOC.SEC)
STATE
TAX
SDI
VACI
HOLIDAY
HEALTH
IWELF.
PENSION 685.81 33302
15687 PALM DR #83
I LABORER
S
8
8
2432
DESERT HOT SPRINGS CA 92240
194.56
972.80
114.38
74.02
33.03
11.61
0.00
0.00
0.00
1
TRAIN.
FUND
ADMIN
DUES
TRAY/
SAVINGS
OTHER'
TOTAL
DEDUC-
TIONS
T
I
0
0.00
0.00
0.00
0.00
0.00
56.22
286.99
LUNA GONZALEZ, CARLOS
I TREE
1 MAINTENANCE
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC SEC)
STATE
TAX
SDI
VACI
HOLIDAY
HEALTH
aI WELF.
PENSION
929.34
33305
66145 7TH ST
I LABORER
S
8
8
27.22
DESERT HOT SPRINGS CA 92240
1
217.76
1088.80
55.16
83.30
7.93
13.07
0.00
0.00
0.00
TRAING.
FUND
DUES
TRAY/
SUES
SAVINGS
OTHER.
TOTAL
DEDUC-
1
ADMIN
TIONS
T
O
0.00
0.00
0.00
0.00
0.00
0.00
159.46
RAMIREZ, MARCELINO
:TREE
1 MAINTENANCE
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC.SEC.)
STATE
TAX
SDI
VACI
HOLIDAY
HEALTH
& WELF.
pensroN
980.79
33306
1500 E SAN RAFAEL DR #164
I LABORER
S
8
7
29.42
PALM SPRINGS CA 92262
1
235.36
1176.80
63A1
88.56
10.96
13.89
0.00
0.00
0.00
TRAING.
FUND
DUES
TRASURE/
SAVINGS
OTHER-
DEDUC-
1
1
ADMIN
TIOnS
1
G
I,
0.00
0.00
0.00
0.00
0.00
19.19
196.01
1
THIS
ALL
FED-
FICA
STATE
VAC/
HEALTH
J
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
@ WELR
PENSION
1
S
r
TRAINC
FUND
DUES
TRAVI
SUBS
SAVINGS
OTHER'
TOTAL
DEDUC-
1
I
ADMIN
TIONS
I
1
0
N=STRAIGHTTIME
•0111FR-Any other deductions,
contributions
and/or
payments whether or not included or required by prevailing
CERTIFICATION MUST be completed
F.., A-1-Il1 (N-2-90)
0= OVERTIME
wage determinations
must be separately
listed.
Use extra sheet(s) if necessary
(See reverse
SDI=STATE DISABILITY
INSURANCE
side)
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT# & LOCATION
3/21/2021
COLA-#2-TREE/STUMP REMOVAL AVE 54
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
HENRIQUEZ, RUBEN F 48.64 CALSAVERS ROTH IRA
15687 PALM DR #83 5.31 DENTAL INS
DESERT HOT SPRINGS CA 92240
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT# & LOCATION
3/21/2021
COLA-#2-TREE/STUMP REMOVAL AVE 54
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
RAMIREZ, MARCELINO 13.88 HEALTH INS
1500 E SAN RAFAEL DR #164 5.31 DENTAL INS
PALM SPRINGS CA 92262
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
I KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLD-#2-TREEISTUMP REMOVAL AVE 54,4 PAGES
(Description, number of 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.
Date: 03/23/2021
Signature:
A public entity may require a stricter and/or more extensive form of certification.
I
I
California
PUBLIC
WORKS
PAYROLL REPORTING
�,�
Depu1 of
FORM
I
Rment
Industrial
Industrial Rclatans
1 4
��.
Page of
I NAME OF CONTRACTOR:
PWLC
II, INC.
CONTRACTORS
LICENSE NO.:
855783
ADDRESS:
OR SUBCONTRACTOR:
SPECIALITY
LICENSE NO
72350
QUARRY
TRL #A
THOUSAND PALMS CA 92276
PAYROLL N0:1 FINAL
FOR WEEK ENDRJG:
03/21/2021
SELF-MSURED CERTIFICATE NO:
PROJECT OR CONTRACTNO:
DAY
(5)
(()
(J)
WORKERS' COMPENSATION
POLICY NO: yV$D 1151817-10
PROJECT AND LOCATION:
COLQ-CORPYARD-AVE52-TREE
(1)
(2) I (3)
M
T W TH F S S
(7)
(E)
(9)
DATE
NAME, ADDRESS AND
z I WORK
TOTAL
HOURLY
RATE
GROSSAMOUNT
15
16 17 1 E 19 2 D 21
SOCIAL SECURITY NUMBER
a u CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS
NET WGS CHECK
OF EMPLOYEE
4o Fi
AND PAYMENTS
PAID FOR NO
0 0 $?
WEEK
z: w
HOURS WORKED EACH DAY
I TREE
THIS ALL
FED,
FICA
SPATE
VAC/
HEALTH
HENRIQUEZ, RUBEN F
1 MAINTENANCE
PROJECT PROJECTS
TAX
C
(SO.SEC.)
TAX
SDI
HOLIDAY
& WELF,
PENSION 685.81 33302
15687 PALM DR #83
E LABORER S
4
4
24.32
DESERT HOT SPRINGS CA 92240
97.28
972.80
114-38
74.02
33.03
11.61
0.00
0.00
0.00
1
TRAING.
FUND
DUES
TRAY/
SUITS.
SAVINGS
OTHER'
TOTAL
DEDUC-
T G
ADMIN
TIONS
0.00
0.00
0.00
0.00
0.00
56.22
286.99
LUNA GONZALEZ, CARLOS
I TREE
1 MAINTENANCE
THIS
PROJECT
ALL
PROJECTS
FED,TAX
C. S
(SOC. SEC.)
STATE
TAX
SDI
VAC/
HOLD)AY
HEALTH
&WELF.
PENSION
929.34
33305
66145 7TH ST
I LABORER S
4
4
27 22
DESERT HOT SPRINGS CA 92240
I
108.88
1088.80
55.16
83.30
7.93
13.07
0.00
0.00
0.00
I
TRAING.
FUND
DUES
TRAY/
SUBS.
SAVINGS
OTHER-
TOTAL
DEDUC-
1 G
ADMIN
TIONS
0.00
0.00
0.00
0.00
0.00
0.00
159.46
RAMIREZ, MARCELINO
I TREE
I MAINTENANCE
THIS
PROJECT
ALL
PROJECTS
FED,
TAX
FICA
(SOC SEC.)
SPATE
TAX
SDI
VAC/
HOLIDAY
HEALTH
& WELF.
PENSION
980.79
33306
1500 E SAN RAFAEL DR #164
I LABORER S
4
4
29.42
PALM SPRINGS CA 92262
117.68
1176.80
63.41 1
88.56
10.96
13.89
0.00
0.00
0.00
r
TRAING.
FUND
DUES
SUBS.
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
1 G
0.00
0.00
0.00
0.00
0.00
19.19
196.01
I
THIS
ALL
FED.
FICA
STATE
VAC/
HEATH
I
PROJECT
PROJECTS
TAX
(SOC SEC)
TAX
SDI
HOLIDAY
& WELLF.
PENSION
I S
1
TRAING
FUND
DUES
SU&SV/
SAVINGS
OTHER'
DFDUC-
ADMIN
TIONS
= O
S=s'Iltnlclrrnmr:
-OTHER-My other deductions,
contributions
and/or
payments whether or not included or required
by prevailing
CERTIFICATION MUST be completed
F A-l-rn INnc -wD
0=0VERT1 EE
wage determinations
must be separately
listed
Use extra sheet(s) if necessary
SDI = STATF: DISABILITY INSURANCE
(See reverse side)
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
3/21/2021
COLA-CORP YARD-AVE52 TREE REMOVAL/CLEAN UP
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
HENRIQUEZ, RUBEN F 48.64 CALSAVERS ROTH IRA
15687 PALM DR #83 5.31 DENTAL INS
DESERT HOT SPRINGS CA 92240
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT# & LOCATION
3/21/2021
COLQ-CORP YARD-AVE52
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
RAMIREZ, MARCELINO 13.88 HEALTH INS
1500 E SAN RAFAEL DR #164 5.31 DENTAL INS
PALM SPRINGS CA 92262
NOTICE TO PUBLIC ENTITY
For Privacl Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL"CRPVARD-AVE52 TREE REMOVAL -CLEAN, 4 PAGES
(Description, number of 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.
Date: 03/23/2021
Signature: J Z 'J.t'LI-4
A public entity may require a stricter and/or more extensive form of certification.
California PUBLIC WORKS PAYROLL REPORTING FORM
Department of
Industrial Rclalions
Page of
NAME OF CONTRACTOR:
PWLC II, INC.
CONTRACTOR'S
LICENSE NO.: ADDRESS:
OR SUBCONTRACTOR:
SPECIALITY
LICENSE NO : 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
I PAYROLL NO:1
FOR WEEK ENDING:
03/21/2021
SELF -INSURED CERTIFICATE NO: PROJECTOR CONTRACT NO:
WORKERS'COMPENSATIONPOLICY NO: WSD5059867-00 PROJECT AND LOCATION: COLQ146-#2-AVE52-EISENHOVa
(4) DAY
(5)
(6)
m
(I) (2) 1 (3)
M T I W I TH F S S
(7) (S) (9)
t
NAME, ADDRESS AND y1 WORK
DATE
TOTAL
HOURLY
RATE
GROSS AMOUNT
15 16 17 16 19 2 0 21
SOCIAL SECURITY NUMBER 3 o F CLASSIFICATION
HOURS
OF PAY
NET WGS CHECK
EARNED DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS PAID FOR NO
OF EMPLOYEE o & I
0 0" y 1
WEEK
HOURS WORKED EACH DAY
I LANDSCAPE
THIS I ALL FED. FICA STATE VAC/ HEALTH
SDI 652.90 33273
DIMAS, PEDRO REYES I MAINTENANCE
PROJECT PROJECTS TAX IS TAX TAX HOLIDAY l4 WELF. PENSION
31-900 AVENIDA EL MUNDO I LABORER
S
8 8 8 8
32
18.00
CATHEDRAL CITY CA 92234 1
576.00
720.00
3.25
55.08
.13
8.64
0.00
0.00
0.00
TRAING.
FUND
DUES
SUBS.
SAVINGS
OTHER'
DEDUC-
]
]
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
67.10
[LANDSCAPE
THIS
ALL
FAD
FICA
STATE
SDI
&WELF
546.90
33274
LIMA, CECILIO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC• )
HOLIDAY
PEnslon
69365 VERA DR
I LABORER
S
8
8
8
8
32
15.00
CATHEDRAL CITY CA 92234
1
480.00
600.00
0.00
45.90
0.00
7.20
0.00
0.00
0.00
]
TRAING.
FUND
DUES
SUMS/
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
53.10
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
472.89
33275
VALDEZ CISNEROS. SALVADOR
1 MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. sec•)
TAX
HOLIDAY
m WELF.
PENSION
12966 CACTUS DR
I LABORER
S
8
8
8
8
32
15.00
DESERT HOT SPRINGS CA 92240
1
480.00
600.00
36.54
45.90
7.47
7.20
0.00
0.00
0.00
TRAING
FUND
DUES
V/
suns.
SAVINGS
OTHER'
TOTAL
DEDUC-
T
ADM.,
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
30.00
127.11
THIS
ALL
FED
FICA
STATE
VACI
HEALTH
PROJECT
PROJECTS
TAX
SOC. SEC.
1 )
TAX
SDI
HOLIDAY
WE
N. F
PENSION
I
S
1
TRAING
DUES
SUass.
SAVINGS
OTHER-
DEDUC-
AFUN DMIN
TIONS
I
0
S=%I3(A1UU'f TIMFt -OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Rn i A-1-111 (Nm2-90) O=OVER nME wage determinations must be separately listed Use extra sheet(s) if necessary (See reverse side)
SDI = Sl'A rE DI WIILITY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT# & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
3/21/2021
COLQ146-#2 AVE52 EISENHOWER-BERMUDAS
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
30.00
NOTICE TO PUBLIC ENTITY
For Privacy_Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL0146-#2-AVE52-EISENHOWER-BERMUOAS, 3 PAGES
(Description, number of 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.
Date: 3/23/2021
Signature:
A public entity may require a stricter and/or more extensive form of certification.
,604 California
Dcport-menl of
Industrial Relations
PUBLIC WORKS PAYROLL REPORTING FORM
Page
f NAME OF CONTRACTOR: CONTRACTORS LICENSE NO.: ADDRESS.
PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO :
I PAYROLL NO: 2 FINAL FOR WEEK ENDING: 03/28/2021 SELF -INSURED CERTIFICATE NO: PROJECT OR CONTRACT NO:
COLQ146-#2-AVE52-EISENHONi
(4) DAY (5) (6) WORKERS'COMPENSATION POLICY NO: WSD 5059867-00 PROJECT AND LOCATION:
(I)
(2) t (3)
M I T W TH I F I S I S
('))
(S)
(9)
DATE
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NAME, ADDRESS AND
r
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22 23 24 1 25 26 27 2R
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o a r
WEEK
r
z s
HOURS WORKED EACH DAY
[LANDSCAPE
THIS
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SDI
VAC/
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472.89
33420
VALDEZ CISNEROS, SALVADOR
I MAINTENANCE
PROJECT
PROJECTS
TAX
(Soc. SEC.)
TAX
HOLIDAY
& WELF.
12966 CACTUS DR
1 LABORER
s
4
4
15.00
DESERT
DESERT HOT SPRINGS CA 92240
60.00
600.00
36.54
45.90
7.47
7.20
0.00
0.00
0.00
1
TRAING.
FUND
DUES
VI
SUUBBSS-
SAVINGS
OTHER'
TOTAL
DEDUC-
ADMIN
TIONS
I
D
0.00
0.00
0.00
0.00
0.00
30.00
127.11
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
545.73
33419
LIMA, CECILIO
1 MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
HOLIDAY
& WELF
69365 VERA DR
1 LABORER
g
4
4
15.0060.00
CATHEDRAL CITY CA 92234
600.00
0.00
45.90
1.17
7.20
0.00
0.00
0.00
1
TRAING.
FUND
DUES
RAW
St1
SAVINGS
OTHER.
TOTAL
DEDUC-
1
1
ADMIN
TIONs
r
0
0.00
0.00
0.00
0.00
0.00
0.00
54.27
I
THIS
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FED.
FICA
STATE
VAC/
HEALTH
PROJECT
PROJECTS
TAX
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SDI
HOLIDAY
& WELF.
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S
1
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R-,A-1-171 (New2-80) D=OVERTIME wage determinations must be separately listed Use extra sheet(s) if necessary (See reverse side)
81)1= ti I'Alli DISADILITY INSl1RANCE•
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
3/28/2021
COLQ146-#2 AVE52 EISENHOWER-BERMUDAS
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
30.00
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL0146-p2-AVE52-EISENHOWER-9ERMUDAS-3 PAGES
(Description, number of 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.
Date: 3/31 /2021
Signature: -a�
A public entity may require a stricter and/or more extensive form of certification.
( ` I
_��� Coliramin PUBLIC WORKS PAYROLL REPORTING FORM
iil Dcparuncnt or
Industrial Relations
Page
r
NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO,: ADDRESS:
[ PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO
PAYROLLNO:1 FINAL FOR WEEK ENDING: 04/11/2021 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO:
COLQ147-AVE52/BERM U DAS-D:
(4) DAY (5) (G) WORKERS' COMPENSATION POLICY NO: WSD 5059867-00 PROJECT AND LOCATION
(I)
NAME, ADDRESS AND
SOCIAL SECURITY NUMBER
OF EMPLOYEE
(2) 1 (3)
[
i I WORK
3 0 22 CLASSIFICATION
o o � [
M I T I W TH I F I S I S
TOTAL
HOURS
HOURLY
RATE
OF PAY
(7)
GROSS AMOUNT
EARNED
(E)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
(J)
DATE
NET WGS
PAID FOR
WEEK
CHECK
NO
05 0 6 07 08 0 9 10 11
HOURS WORKED EACH DAY
z o I
DIMAS, PEDRO REYES
31-900 AVENIDA EL MUNDO
CATHEDRAL CITY CA 92234
[ LANDSCAPE
I MAINTENANCE
I LABORER
S
8
B
4.5
20.5
18.00
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC. SEC)
STATE
TAX
SDI
VACI
IIOLIDAY
HEALTH
&WELF.
PENSION
608.12
33591
369.00
720.00
40.67
55.08
7.49
8.64
0.00
0.00
0.00
TRAING.
FUND
ADMIN
DUES
TRAYI
SUBS.
SAVINGS
OTHER-
TOTAL
DEDUC-
TIONS
[
0.00
0.00
0.00
0.00
0.00
0.00
111.88
I
0
E
LIMA, CECILIO
69365 VERA DR
CATHEDRAL CITY CA 92234
I LANDSCAPE
I MAINTENANCE
I LABORER
S
8
8
8
4.5
28.5
15.00
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(sOC SEC)
STATE
TAX
SDI
VACI
HOLIDAY
HEALTH
& WELF.
Pensron
545.73
33592
417.50
600.00
0.00
45.90
1.17
7.20
0.00
0.00
0.00
TRAING-
FUND
ADMIN
DUES
SUTRABSS.
SAVINGS
OTHER'
DEDUC-
TIONS
T
�
0
0.00
0.00
0.00
0.00
0.00
0.00
54.27
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT
DESERT HOT SPRINGS CA 92240
I LANDSCAPE
IMAINTENANCE
I LABORER
1
S
8
8
8
4.5
28.5
15.00
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
IS
STATE
TAX
SDI
VAC/
HOLIDAY
HEALTH
&WELF.
PENSION
472.89
33593
427.50
600.00
36.54
45.90
7.47
7.20
0.00
0.00
0.00
TRAING.
FUND
ADMIN
DUES
SU�RSVI
SAVINGS
OTHER-
TOTAL
DEDUC-
TIONS
1
T
I
0
I
0.00
0.00
0.00
0.00
0.00
30.00
127.11
I
1
THIS
PROJECT
ALL
PROJECTS
FED.
TAX
FICA
(SOC-SEC-)
STATE
TAX
SDI
VACI
HOLIDAY
HEALTII
&WELF.
PENSION
I
S
1
E
!
TRAING.
FUND
ADMIN
DUES
SSUUBS.
SAVINGS
OTHER'
DEDUC-
TIONS
E
0
S=STRAIOIrr TIME-oTirER-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
F-A-i-131 IN-2-84r) o=ovERrIME wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SDI =STATE DISABILITY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT# & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
4/11/2021
COLQ147-AVE52/BERMUDAS-DESERT CLUB
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
30.00
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL0147-AVE52-BERMUDAS-DESERT CLUB, 3 PAGES
(Description, number of 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.
Date: 4/13/2021
Signature:z
A public entity may require a stricter and/or more extensive form of certification.
r-
_p� f
ii■ Colifortmemiant PUBLIC WORKS PAYROLL REPORTING FORM Depoo
Industrial Relations
Page
i NAME OF CONTRACTOR: CONTRACTORS LICENSE NO ADDRESS.
PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO:
I PAYROLLNO:1 FINAL FOR WEEK ENDING: 04/18/2021 SELF -INSURED CERTIFICATE NO: PROJECTOR CONTRACT NO:
COLQ151-1-AVE52/JEEP#1 PLAT
(4) DAY (S) (6) WORKERTCOMPENSATION POLICY NO.: WSD 5059867-00 PROJECT AND LOCATION:
(I)
p) I (3)
M I T I W TH F S S
(7)
DATE
NET WGS
CHECK
NAME, ADDRESS AND
z I WOE
TOTAL
HOURLY
RATE
GROSS AMOUNT
12 13 14 15 16 17 1 B
SOCIAL SECURITY NUMBER
s O O CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO
OF EMPLOYEE
o o I
I
WEEK
z
HOURS WORKED EACH DAY
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEAT
608.12
33624
DIMAS, PEDRO REYES
1 MAINTENANCE
PROJECT
PROJECTS
TAX
(soc SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
EL MUNDO
I LABORER
S
8
8
16
18.00
CATHEDRAL
DRALAVENCI
CATHEDRAL CITY CA 92234
I
288.00
720.00
40.67
55.08
7.49
8.64
0.00
0.00
0.00
TRAING.
FUND
DUES
RAY/
SUUIM
SAVINGS
OTHER'
TOTAL
D DUC-
T
ADMIN
TIONS
I
O
0.00
0.00
0.00
0.00
0.00
0.00
111.88
I LANDSCAPE
THIS
ALL
FED,
FICA
STATE
VAC/
HEALTH
545.73
33625
LIMA, CECILIO
IMAINTENANCE
PROJECT
PROJECTS
TAX
(soc.SEC)
TAX
SDI
HOLIDAY
&WELF.
PENSION
69365 VERA DR
I LABORER
S
8
8
16
15.00
CATHEDRAL CITY CA 92234
I
240.00
600.00
0.00
45.90
1.17
7.20
0.00
0.00
0.00
TRAING,
FUND
DUES
SUBS.
SAVINGS
OTHER'
D DUC-
VOW
T
ADMIX
TIONS
O
0.00
0.00
0.00
0.00
0.00
0.00
54.27
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAc/
HEALTH
PENSION
472.89
33626
VALDEZ CISNEROS, SALVADOR
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. sec.)
TAX
HOLIDAY
& WELF.
12966 CACTUS DR
I LABORER
S
8
8
16
15.00
DESERT HOT SPRINGS CA 92240
240.00
600.00
36.54
45.90
7.47
7.20
0.00
0.00
0.00
I
TRATOTAL
TRAING.
FUND
DUES
SUBM
SAVINGS
OTHER-
DEDUC-
T
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
30.00
127.11
I
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
SDI
HOLIDAY
&WELF.
PENSION
1
S
TOTAL
TRAING.
FUND
DUES
SUUBSV/
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
I
O
S=S1RAIOIITTIME •crrlir•R-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Fomr A -but (New i-w)) O=OVERTIME wage determinations must be separately listed Use extra sheet(s) if necessary (See reverse side)
SDI = STATE DISABILITY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT # & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
4/18/2021
COLQ151-1-AVE52/JEFF#1 PLANTS
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
30.00
NOTICE TO PUBLIC ENTITY
For Privacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Nance — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL0151.1-AVE52fJEFF&1 PLANTS, 3 PnGES
(Description, number of 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.
Date: 4/20/2021
Signature:'`�'��
A public entity may require a stricter and/or more extensive form of certification.
CHNCalifornia PUBLIC WORKS PAYROLL REPORTING FORM
Depunment or
Indusuinl Relations
Page
NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO ADDRESS:
r PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO
1 PAYROLL NO:1 FINAL FOR WEEK ENDING: Q4/18/2021 SELF -INSURED CERTIFICATE NO: PROJECT OR CONTRACT NO.:
COLQ152-2-AVE52/JEEP#2 PLAI'
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO : WSD 5111167-10 PROJECT AND LOCATION:
(1)
(2) 1 (3)
M I T W TH I F I S I S
(7)
(S)
())
t
HOURLY
NAME, ADDRESS AND
z WORK
1
DATE
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
12 13 14 15 1 6 17 1 B
SOCIAL SECURITY NUMBER
R.0 CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO
OF EMPLOYEE
o o 1
�
WEEK
i o 1
HOURS WORKED EACH DAY
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSIONS
608.12
33624
DIMAS, PEDRO REYES
i MAINTENANCE
16
PROJECT
PROJECTS
TAX
(SOC. sec)
TAX
HOLIDAY
6 WELF.
31-900 AVENIDA EL MUNDO
I LABORER
B
B
18.00
CATHEDRAL CITY CA 92234
288.00
720.00
40.67
55.08
7.49
8.64
0.00
0.00
0.00
TRANI
TOTAL
t
r
TRAING.
FUND
ADMIN
DUES
SUBS.
SAVINGS
OTHER-
DED C-
TIONS
O
r
0.00
0.00
0.00
0.00
0.00
0.00
111.88
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
pension
545.73
33625
LIMA, CECILIO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
HOLIDAY
6 WELF.
69365 VERA DR
I LABORER
S
6
6
16
15.00
CATHEDRAL CITY CA 92234
240.00
600.0
0.00
45.90
1.17
7.20
0.00
0.00
0.00
W
TOTAL
TRAING.
FUND
DUES
SUUBBSS.
SAVINGS
OTHER-
DEDUC-
I
ADMIN
TNONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
54.27
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
472.89
33626
VALDEZ CISNEROS, SALVADOR
1 MAINTENANCE
15.00
PROJECT
PROJECTS
TAX
(SOC. sec.)
TAX
II
C, WELF.
240.00
600.00
36.54
45.90
7.47
7.20
0.00
0.00
0.00
12966 CACTUS DR
I LABORER
S
8
8
16
DESERT HOT SPRINGS CA 92240
1
TRAV/
TOTAL
I
TRAING_
FUND
DUES
SUS•
SAVINGS
OTHER'
DEDUC
T
ADMIN
TIONS
TIONS
I
0
I
0.00
0.00
0.00
0.00
0.00
30.00
127.11
]
THIS
ALL
FED
FICA
STATE
VAC/
HEALTH
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
&WELF.
PENSION
I
S
TOTAL
1
TRAING
FUND
AD'MIN
DUES
SUURSV/
SAVINGS
OTHER'
DEDUC-
TIONS
I
0
S=S RAIoirrTIME-oTilrR-Any other deductions, contribulions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
F.-A-1-131 (N-2-WI) O=OVERTIME wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SDI = STATE DISABILITY INSURANCE
PUBLIC WORKS PAYROLL REPORTING FORM A-1-131
PWLC II, INC.
WEEK ENDING
PROJECT# & LOCATION
VALDEZ CISNEROS, SALVADOR
12966 CACTUS DR
DESERT HOT SPRINGS CA 92240
*OTHER = CALSAVERS ROTH IRA
4/18/2021
COLQ152-2-AVE52/JEFF #2 PLANTS
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
OTHER*
30.00
61
NOTICE TO PUBLIC ENTITY
For Privacv Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL4152.2-AVE521JEFFM12PEAHTS.3 PAGES
(Description, number of 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.
Date: 4/21 /2021
Signature:"""`
A public entity may require a stricter and/or more extensive form of certification.
��Calirumia PUBLIC WORKS PAYROLL REPORTING FORM
!■■1 Department of
Industrial Relations
Page
NAME OF CONTRACTOR: CONTRACTORS LICENSE NO: ADDRESS.
PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
! PAYROLL NO.:1 FINAL FOR WEEK ENDING: 04/25/2021 SELF -INSURED CERTIFICATE NO: PROJECT OR CONTRACT NO:
COLQ153-AVE52-JEFF ROUND
(4) DAY (5) (fi) WORKERS'COMPENSATION POLICY NO.: WSD 5059867-00 PROJECT AND LOCATION:
(1)
(2) 1 (3)
M I T I W TH I F I S I S
(7)
IN)
(9)
DATE
HOURLY
NAME, ADDRESS AND
i I WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
19 2 0 21 2 2 2 3 2 4 2 5
SOCIAL SECURITY NUMBER
s o F CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO
OF EMPLOYEE
o In 6 I
WEEK
°z � I
s
HOURS WORKED EACH DAY
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
I[EALTH
PENSION
608.12
33655
DIMAS, PEDRO REYES
1 MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. sec.)
TAX
HOLIDAY
& WELF.
31-900 AVENIDA EL MUNDO
I LABORER
S
8
8
18.00
CATHEDRAL CITY CA 92234
144.00
720.00
40.67
55.08
7.49
8.64
0.00
0.00
0.00
TRAINC.
FUND
DUES
SUUHSVI
SAVINGS
OTHER'
DEDUC-
!
TIONS
I
O
0.00
0.00
0.00
0.00
0.00
0.00
111.88
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
566.91
33656/6
LIMA, CECILIO
IMAINTENANCE
PROJECT
PROJECTS
TAX
(sOC.SEC)
TAX
SDI
HOLIDAY
&WELF.
PENSION
365
69365 VERA DR
!LABORER
S
8
8
16
15.00
CATHEDRAL CITY CA 92234
I
240.00
622.50
0.00
47.61
.51
7.47
0.00
0.00
0.00
TRAING.
FUND
DUES
TRAVTOTAL
S DSI
SAVINGS
DTHER•
DEDUC-
1
ADMIN
TIONS
!
O
0.00
0.00
0.00
0.00
0.00
0.00
55.59
I LANDSCAPE
THIS
ALL
FED.
FICA
SPATE
VAC/
HEALTH
567.42
3365716
LIMA, RUDOLFO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
5D1
HOLIDAY
& WELF.
PENSION
363
33975 RANCHO VISTA DR
I LABORER
S
8
8
1 g
15.00
CATHEDRAL CITY CA 92234
I
240.00
622.50
0.00
47.61
0.00
7.47
0.00
0.00
0.00
TRAING.
FUND
DUES
TRAVI
suns.
SAVINGS
OTHER-
TOTAL
DEDUC-
I
E
ADMIN
TIONS
1
0
0.00
0.00
0.00
0.00
0.00
0.00
55.08
1
1
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
!
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
&WELF.
PENSION
!
S
!
TRAV/SUBS.
L
TRATNG.
FUNTOT
D
DUES
SAVINGS
OTHER-
DEDUC-
ADMIN
TIONS
I
0
S STRAIGIrr TIME •OTHER -Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be Completed
F-A-l-Ill (N-240) O=OVERTIME wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SIX = STATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
I KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLO753-AVE52-JEFF ROUND CORNEM, 2 PAGES
(Description, number of 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.
Date: 05/04/2021
Signature: 6
A public entity may require a stricter and/or more extensive form of certification.
_■M� CaIJ rnia PUBLIC WORKS PAYROLL REPORTING FORM
i■1 Department of
Industrial Relations
Page of
NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO: ADDRESS.
PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO
I PAYROLLNO:I FINAL FOR WEEK ENDING: 04/25/2021 SELF -INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.:
COLQ154-AVE52-JEFF ROUND
(I) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: WSD 5151167-00 PROJECT AND LOCATION:
(1)
(2) I (J)
M T W TH I F I S I S
(7)
DATE
HOURLY
NAME, ADDRESS AND
Q I WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
19 2 0 21 2 2 2 3 2 4 2 5
SOCIAL SECURITY NUMBER
3 0 - CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO
OF EMPLOYEE
o c I
WEEK
HOURS WORKED EACH DAY
z I
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
608.12
33655
DIMAS, PEDRO REYES
I MAINTENANCE
PROJECT
PROJECTS
TAR
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
31-900 AVENIDA EL MUNDO
I LABORER
S
8
8
18.00
CATHEDRAL CITY CA 92234
144.00
720.00
40.67
55.08
7.49
8.64
0.00
0.00
0.00
I
TRAING.
FUND
DUES
TRAVr
SUBS.
SAVINGS
OTHER'
TOTAL
DEDUC-
T
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
111.88
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
566.91
33656I6
LIMA, CECILIO
1 MAINTENANCE
PROJECT
PROJECTS
TAX
(sOC. SEC.)
TAX
HOLIDAY
& WELF.
336
65
69365 VERA DR
I LABORER
S
8
8
16
15.00
CATHEDRAL CITY CA 92234
I
262.50
622.50
0.00
47.61
.51
7.47
0.00
0.00
0.00
TRAING.
FUND
DUES
TRAY
SUBS'
SAVINGS
OTHER-
TOTAL
DEDUC-
1
ADMIN
TIONS
O
1
22.50
0.00
0.00
0.00
0.00
0.00
0.00
55.59
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
567.42
33657/6
LIMA, RUDOLFO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC)
TAX
HOLIDAY
& WELF.
336
63
33975 RANCHO VISTA DR
I LABORER
S
8
8
15
15.00
CATHEDRAL CITY CA 92234
I
262.50
622.50
0.00
47.61
0.00
7.47
0.00
0.00
0.00
TRAVr
TOTAL
TRAING.
FUND
DUES
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
I
O
1
1
22.50
0.00
0.00
0.00
0.00
0.00
0.00
55.08
I
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
'
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
I HOLIDAY
& WELF.
PENSION
1
S
I
TRAING.
FUND
DUES
SUBS
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
i
I
0
S=SI`RAJGTrrTIME -oTnFR-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Fnm. A-l-III (N-2-M) O=DVERTIME wage determinations must be separately listed. Use extra sheet(s) if necessary (See reverse side)
SDI = STATT: DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privaev Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLQ154-AVE52-JEFF ROUND CORNER#4, 2 PAGES
(Description, number of 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.
Date: 5/4/2021
Signature: Z�`
A public entity may require a stricter and/or more extensive form of certification.
_■;� Calfomia
Dcpnrtmenl of PUBLIC WORKS PAYROLL REPORTING FORM
�■
Industrial Relations
Page
' NAME OF CONTRACTOR: CONTRACTORS LICENSE NO! ADDRESS.
PWLC II, INC. 655763 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO.:
I PAYROLLNO:1 FINAL FOR WEEK ENDING: 04/25/2021 SELF -INSURED CERTIFICATE NO: PROJECT OR CONTRACTNO:
COLQ156-PT HAPPY N OF HWY
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO: WSD 5059867-00 PROJECT AND LOCATION:
(I)
(2) 1 (3)
M I T I W TH I F I S I S
(7)
DATE
HOURLY
NAME, ADDRESS AND
z I WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
19 120 21 1 22 23 24 125
SOCIAL SECURITY NUMBER
5 O F�� CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO
OF EMPLOYEE
o o " 1
WEEK
HOURS WORKED EACH DAY
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VAC/
HEALTH
PENSION
567.42
33657/6
LIMA, RUDOLFO
IMAINTENANCE
PROJECT
PROJECTS
TAX
(sOC.SEC)
TAX
HOLIDAY
&WELF.
36360.00
33975 RANCHO VISTA DR
I LABORER
S
4
4
15.00
CATHEDRAL CITY CA 92234
I
622.50
0.00
47.61
0.00
7.47
0.00
0.00
0.00
TRAING.
FUND
DUES
SUUBBSV/
SAVINGS
OTHER-
TOTAL
DEDUC-
T
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
55.06
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
566.91
33656/6
LIMA, CECILIO
1 MAINTENANCE
PROJECT'
PROJECTS
TAX
(sOC. sec.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
365
69365 VERA DR
I LABORER
S
4
4
15.00
CATHEDRAL CITY CA 92234
I
60.00
622.50
0.00
47.61
.51
7.47
0.00
0.00
0.00
TRAING
FUND
DUES
SUTUTRBSV/
SAVINGS
OTHER-
DEDUC-
ITOTAL
T
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
55.59
I
THIS
ALL
D.
FICA
STATE
I
PROJECT
PROJECTS
TTAAX
(SOC SEC. )
SDI
HOLIDAY
& WE F
PENSION
I
S
0.00
VI
TOTAL
1
TRAING.
FUND
DUES
SUBS.
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
51.76
THIS
ALL
FED.
FICA
SPATE
VAC/
HEA LTH
I
PROJECT
PROJECTS
TAX
(SO. SEC.)
C
TAX
SDI
HOLIDAY
& WELF.
PENSION
I
I
S
TRAV/
TRAING.
FUND
DUES
Suit"T
SAVINGS
OTHER'
DEDUTOTAL
ADMIN
TIONS TIONS
l
0
s=s77tAIGIrrIIMls•oIHER - Any other deductions, contribulionsand/or payments whether or not i ncluded or requi red by prevail ing CERTIFICATION MUST be completed
r m,A-I-m (N-2-M) O=OVERTIME wage determinations must be separately listed Use extra sheet(s) iFnecessary (See reverse side)
sD1 = STAI E DI.SADTLIIY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
1 KRISTY SOUTH
(Name — print)
_CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL015H-PT HAPPY N OF HVJY 7 i1•MDUNT, IPAGES
(Description, number of 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.
Date: 5/4/2021
Signature: Z 111�a `&
tv
A public entity may require a stricter and/or more extensive form of certification.
�;�Califomia PUBLIC WORKS PAYROLL REPORTING FORM
Dcpartmcnt of
Industrial Relaliow
Page
1 NAME OF CONTRACTOR: CONTRACTORS LICENSE NO: ADDRESS:
PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO:
I PAYROLL NO:1 FOR WEEK ENDING: 05/02/2021 SELF -INSURED CERTIFICATE NO: PROJECTOR CONTRACT NO:
COLQ155-AVE52 8 JEFF ROUNI
(J) DAY (5) (6) WORKERS' COMPENSATION POLICY NO: WSD 5059867-00 PROJECT AND LOCATION:
(I)
(2) I (3)
M I T I W TH I F I S S
(7)
DATE
--
HOURLY
AND
I WORK
TOTAL
RATE
SS
GROEARN
NETWGS
C
26 27 28 29 30 01 02
SOC AnL SECDDRESS UR TY NUMBER
u g CLASSIFICATION
HOURS
0 PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.K
OF EMPLOYEE
I
o o
WEEK
HOURS WORKED EACH DAY
Z I
�
I LANDSCAPE
THIS
ALL
FED.
FICA
SPATE
VACI
HEALTH
608.12
33792
DIMAS, PEDRO REYES
I MAINTENANCE
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
31-900 AVENIDA EL MUNDO
I LABORER
S
8
8
8
8
8
40PROJECT
1 B.00
CATHEDRAL CITY CA 92234
I
720.00
720.00
40.67
55.08
7.49
8.64
0.00
0.00
0.00
VI
TOTAL
TRAING.
FUND
DUES
SUBS.
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
I
0
0.00
0.00
0.00
0.00
0.00
0.00
111.88
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
SDI
VACI
HEALTH
PENSION
545.72
33793
LIMA, CECILIO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAX
HOLIDAY
& WELF.
69365 VERA DR
I LABORER
S
8
8
8
8
8
40
15.00
CATHEDRAL CITY CA 92234
I
600.00
600.00
0.00
45.91
1.17
7.20
0.00
0.00
0.00
TOTAL
TRADIG.
FUND
DUES
SUBS.
SAVINGS
OTHER'
DEDUC-
T
ADMIN
TIONS
I
0
I LANDSCAPE
0.00
0.00
0.00
0.00
0.00
0.00
54.28
THIS
ALL
FED.
FICA
STATE
VACI
HEALTH
546.90
6364
LIMA, RUDOLFO
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
33975 RANCHO VISTA DR
1 LABORER
S
8
8
8
8
B
40
15.00
CATHEDRAL CITY CA 92234
600.00
600.00
0.00
45.90
0.00
7.20
0.00
0.00
0.00
1
7RAINC.
FOND
DUES
SURE
SAVINGS
OTHER'
DEDUC-
I
T
ADMIN
TIONS
I
0
I
0.00
0.00
0.00
0.00
0.00
0.00
53.10
I
THIS
ALL
FED
FICA
STATE
SDI
VACI
HEALTH
PENSION
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
HOLIDAY
& WELF.
I
S
I
TOTAL
TRAINC
FUND
DUES
SUUBBS.
SAVINGS
OTHER•
DEDUC-
T
ADMIN
TIONS
I
D
S=NTRNUIIT 7IME -OTHER- Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Fmm A-1-131 (11-2-W) O=OVFRTIME wage determinations must be separately listed Use extra sheet(s) if necessary (See reverse side)
Not=tiTATE DISABILITY INSURANCE
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
I,
KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COL0155-AVE52 & JEFF ROUNDABOUT, 2 PAGES
(Description, number of 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.
Date: 05/04/2021
Signature: O'Zt
A public entity may require a stricter and/or more extensive form of certification.
_■MM Caliromia PUBLIC WORKS PAYROLL REPORTING FORM
�i Department or
Industnol Relations
Page of
f NAME OF CONTRACTOR: CONTRACTORS LICENSE NO: ADDRESS.
PWLC II, INC. 855783 72350 QUARRY TRL #A THOUSAND PALMS CA 92276
OR SUBCONTRACTOR: SPECIALITY LICENSE NO:
I PAYROLL N0.: 2 FINAL FOR WEEK ENDING: 05/09/2021 SELF -INSURED CERTIFICATE NO: PROJECT OR CONTRACT NO:
COLQ155-AVE52 & JEFF ROUNI
(4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: WSD 5059867-00 PROJECT AND LOCATION:
0
(I)
(2) T (3)
M I T I W TH I F I S I S
(7)
(E)
(9)
HOURLY
DATE
NAME, ADDRESS AND
> WORK
I
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
0 3 04 0 S 0 6 0 7 0 8 D 9
SOCIAL SECURITY NUMBER
3 ° ° . CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO
OF EMPLOYEE
o o '
WEEK
°z I
s'.w
HOURS WORKED EACH DAY
I LANDSCAPE
THIS
ALL
FED-
FICA
STATE
SDI
VAC/
HEALTH
526.81
33825
DIMAS, PEDRO REYES
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
HOLIDAY
& WELF.
pensJon
31-900 AVENIDA EL MUNDO
I LABORER
S
8
8
B
24
18.00
CATHEDRAL CITY CA 92234
1
472.50
616.50
29.92
47.16
5.21
7.40
0.00
0.00
0.00
1
TRAING.
FUND
DUES
SUBS
SAVINGS
OTHER'
TOTAL
DEDUC-
I
T
1.5
27.00
ADMIN
TIONS
I
o
1.5
0.00
0.00
0.00
0.00
0.00
0.00
89.69
I LANDSCAPE
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
PENSION
575.02
33826
LIMA, CECILIO
IMAINTENANCE
PROJECT
PROJECTS
TAX
(SOC.SEC.)
TAXSDI
HOLIDAY
&WELF.
69365 VERA DR
I LABORER
S
6
8
8
24
15.00
CATHEDRAL CITY CA 92234
I
393.75
633.75
0.00
48.47
2.65
7.61
0.00
0.00
0.00
TRAING.
FUND
DUES
SUBS.
SAVINGS
OTHER'
DEDUC-
1.5
1.5
22.50
ADMIN
TIONS
0
0.00
0.00
0.00
0.00
0.00
0.00
58.73
I LANDSCAPE
THIS
ALL
FED,
FICA
STATE
VAC/
HEALTH
693.19
33827
NAVARRO MERCADO, JOSE R
I MAINTENANCE
PROJECT
PROJECTS
TAX
(SOC. SEC.)
TAX
SDI
HOLIDAY
& WELF.
PENSION
52736 CALLE AVILA
I LABORER
S
8
8
8
24
18.00
COACHELLA CA 92236
472.50
760.50
0.00
58.18
0.00
9.13
0.00
0.00
0.00
T
TRAVSURS/
TOTAL
'!
TRAING.
FUND
DUES
SAVINGS
OTHER'
DEDUC-
ADMIN
TIONS
�
0
1.5
1.5
27.00
I
0.00
0.00
0.00
0.00
0.00
0.00
67.31
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
PROJECT
PROJECTS
TAX
(SOC.SEC)
TAX
SDI
HOLIDAY
&WELF.
PENSION
I
S
I
TRAING.
FUND
DUES
S-UBBSW
SAVINGS
OTHER-
TOTAL
DEDUC-
T
ADMUi
TIONS
I
0
T
s=STRAIGIrrTIME •OTIn:R-Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION MUST be completed
Fo nA-W31 (N-2-Ma) O=OVERTIME wage determinations must be separately listed Use extra sheets) if necessary (See reverse side)
SDI = S I'A'IE DISAIIILI'rY INSURANCIi
NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 1 I inches)
1 KRISTY SOUTH
(Name — print)
CONTROLLER
(Position in business)
PWLC II, INC.
(Name of business and/or contractor)
the undersigned, am the
with the authority to act for and on behalf of
certify under penalty of perjury
that the records or copies thereof submitted and consisting of COLO155-AVE52 & JEFF ROUNDABOUT, 2 PAGES
(Description, number of 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.
Date: 05/12/2021
Signature:
A public entity may require a stricter and/or more extensive form of certification.