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2021-03-14 and 2021-03-21 Cert Payroll - CORRECTIONSCANCaws PUBLIC WORKS PAYROLL REPORTING FORM Dq=ineat of 11dm1nal Aelrnnr Page NAME OFCONTRACTOR CONTRACTORS LICENSE NO ADDRESS. 72350 QUARRY TRL #A THOUSAND PALMS CA 92278 PWLC II, INC. 855783 OR SUBCONTRACTOR. SPECIALITY LICENSE NO 1 PAYROLLNO 1.1 FINAL FOR IVEEK ENDING 03/1412021 SELF -INSURED CERTIFICATE NO PROJECT Oft CONTRACT NO COLD47-TREEISTUMP REMOV (4) DAY 13) (6) WORKER4COMPEHSATIONPOUCY NO. WSD5059867-00 PROJECT AND LOCATION 0 1 I I I 1 1 1'JI Ill f21 (3) M T WA Tif F S 5 fTJ (L) DATE 11OURLY NAME, ADDRESS AND F I WORK TOTAL RATE GROSS AMOUNT NET WGS CHECK aB 09 30 11 1] 13 14 SOCtALSECUR"NUhIHER s § CLASSIFICATION FI(WRS OF PAY EARNED DEDUCTIONS, CONTRIBUTIONS AND PAYA]ENIS PAID FOR NO OFEMPLOYEE ? c I WEEK ItMRS WORKED EACH DAY z = I TREE Tests ALL Fen. FICA STATE SDI VAG HEALTH PeYsluN 645.22 3326916 HENRIQUEZ. RUBEN F I MAINTENANCE 8 25 17 PROJECT PROTECTS TAX (saC sec] TAX IInL@AY • wELF 532 201.35 892.08 92.13 67.83 26.35 10.64 0.00 0.00 0.00 15687 PALM DR #03 I LABORER S 8 DESERT HOT SPRINGS CA 92240 1 TRAM FUND DUES SUUIM SAVLSG3 OTHER. DEDUC• I 1 An%ty TIIFYS 1 O 0.00 0.40 0.00 0,00 0.00 49.91 246.86 I TREE THIS ALL FED. FICA STATE SD] VAC! UEALTf „SIOY 817.84 33270 PROJECT PROJECTS TAX issECI TAX Ii..AY • wELF. LUNA GONZALEZ, CARLOS I MAINTENANCE 8 27.22 217.75 941.28 37.59 72.01 2,54 11.30 0.00 0.00 0.00 661457THST I LABORER S 8 DESERT HOT SPRINGS CA 92240 I I TRAMC. FIND DUES SU1 IVL SAVLy4S Imotit• DDEDUC. ADML4 TIONS O I 0.00 0.00 0.00 0.00 0.00 0.00 123.44 I TREE THIS ALL FM FICA STATE sn] VAC7 IIIALTFI FeNs1DN 868.12 33271 PROTECT PROJECTS TAX ism SEC) TAX 11OLEDAY • WEu RAMIREZ, MARCELINO I MAINTENANCE 8 29.42 235.36 1026.08 45.33 77.03 4.33 12.68 0.00 0.00 0.00 15M E SAN RAFAEL DR 9164 LABORER S 8 PALM SPRINGS CA 92262 I AVI I TRA1114G FUND DUES SU1 SAVF4Gs "TIER' ED TNAC. ADMIX nUyS D I 0.00 0.00 0,00 0.00 0.00 19.19 157.96 Tilts ALL FED. FICA STATE VAC! HEALTH PROJECT PROJECTS TAX (sac sec.) TAX SDI UOUIDAY &WELF mms1aN I " I 7RAII TOTAL TRAL4a- FUND DUTS SUR4 SAVCGS 11t77[R• DEDU • 1 ADIUM TIOMC T1DN5 I U a-s1RAIWIT "t.1F •tmtrR-Any when deductions• contributions andlar payments whether a not included or mquired by prnatling CERTIFICATION NI W T he completed I« Ad4111rkw T-Fn 0-OV131TI/.o: wage determenati:+li's,ust be separately listed Ule ectra &heeds} if necessary (See rnx side) SIR -STATE In--SA111UTY IKSURANIT. 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* HENRIQUEZ, RUBEN F 44.50 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 It & 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 Considerations Fold back along dotted line prior to copying for release to general public (private persons). (Paper Size then 8-1/2 x I I inches) I 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 COLO-91-TRMSTUNIP REMOVAL AVE 54,4 PAGES (Description, number of pages) are the originals or true, cull, and correct copies of the originals which depict the payroll rccord(s) of the actual disbursements by way of cash, check, or «hatevcr form to the individual or individuals named. Date: 08/05/2021 Signature_ " - '& A public entity may require a stricter and/or more extensive form of certification. CANCallfwnu PUBLIC WORKS PAYROLL REPORTING FORM Dep mt u LIT Indwlnal Rd+Iwm Page 1 NAME OFCONTAACTOR PWLC II. INC. CONTRACTOR'S LICENSE NO 855783 ADDRESS 72350 QUARRY TRL #A THOUSAND PALMS CA 92276 OR SUBCONTRACTOR sPEnALFI'Y LICENSE NO PAYROLLNO 1-1 FINAL FOR WEEKENDING 03114/2021 SELF -INSURED CERTIFICATE NO PROJECT OR CONTRACT NO COLO•TREEISTVMP REMOVAL 1+1 DAY is) (6) WORKEICSCOMPElNSATIOYPOLICYNO WS05059867.00 PROJECT AND LOCATION 0 1 I I I I 1 1'IJ lq [!1 pJ t,t T W T!! F S S fTl (1) DATE I IMPLY N&kM ADDRESS AND I WORK TOTAL RATE GROSS AMOUNT bEIH1CTlONS,CONTRIBUnONS AND PAYMENTS NETWGS CHECK NO OB 09 LO 11 12 I3 Ii SOCIAL SECURITY NUMBER" CLASSIFICATION EIQVRS OF PAY EARNED PAID FOA OFEMPLOVEE WEEK IIOURS WORDED EACH DAY TREE Tests ALL FTO. FICA 'STATE sn[ vacl IIEALnI rurstON 645.22 3326916 HENRIQUEZ, RUBEN F I MAINTENANCE 1D 2517 PROJECT PROIECTS TAX Isoc. srC) TAX nouDAV a WELF. 532 251.70 892.08 92.13 67.83 26.35 10.64 0.00 0.00 0,00 1 %87 PALM DR #83 I LABORER S 8 2 DESERT HOT SPRINGS CA 92240 1 TRAM. FUND OVES TRAAVI SAVINGS OTHER• TOTAL - 1 1 ADINLV Tram Q I 0.00 0.00 0.00 0.00 0.00 49.91 246,86 I TREE Tills ALL FED FICA STATE SDI VAC/ t1EALTo PESSION 817.84 33270 PROJECT PROJECTS TAX ISOSECT C TAx HOLIDAY ♦ WIL LUNA GONZAI E. CARLOS I MAINTENANCE 8 2 10 27.22 272.20 941.28 37.59 72.01 2.54 11,38 0.00 0.00 0.00 66145 7TH ST I LABORER s DESERT HOT SPRINGS CA 92240 TRAM. FUND DUES SUM SAVINGS on1EA• TOTAL I ADNLY TINS O I 0.00 0.00 0.00 0.00 0.00 0.04 123.44 I TREE Tills ALL FEN. RCA STATE SDI VACI IMALn[ PTIISION 858.12 33271 PROJECT PROJECTS TAX tsOCsECI TAX HOLUIAY • WELF. RAMIREZ, MARCELINO 1 MAINTENANCE e 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 DR 9164 I LABOREi2 S PALM SPRINGS CA 92262 I TRAmG FUND DUES SWIM. sV%. SAVINGS OTHER• TOTAL bED I 1 ADMLV T1aNS 0.00 0.00 0.00 0.00 0,00 19.19 157.96 1 1 Tills ALL Im FICA STATE SDI VACI IIEALn[ PE.`NstoN I PROIECT PROJECTS T+ 1soC SE�i TAX IIOUDAY i WELi I TILAI NG FUND DUES � SU � SAVINGS OTHER• TOTAL bEDUC- 1 MsILY TIONS 1 ° a-SIRA(;IITIIW Nmn-R-Any other deductions, contributions and/or paymenis ulhetherornot included at aquired by Prevailing CERTIFICATION '*IIJS-1'becompleted I'nm A-I-t+1 lN,► T->ol 41-0WRITSD: Wage determinations must be separmdy lislnl llse Naha shect(s) if ncceBsary (see reverse side) SI)t - STAW IWW RLOY UOMANLM 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* HENRIQUEZ, RUBEN F 44.6 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-MADISON-TREE/STUMP REMOVAL (8) DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS OTHER* RAMIREZ, MARCELINO 13.88 HEALTH INS 1500 E SAN RAFAEL OR #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 Sire then 8- 112 a 11 inches) l KRISTY SOUTH the undersigned, am the (Name — print) CONTROLLER ith the authority to act for and on behalf of (Position in business) PWLC 11, INC. certify under penalty of perjury (Name of business and/or contractor) that the records or copies thereof submitted and consisting of COLA-Tkr:ElsTUMP REMOVAL MADISON, 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 "ay of cash, check, or %%hatc%cr form to the individual or individuals named. Date, 081051202'1 Signature_ ,�✓ A public entity may require a stricter and/or more extensive form of certification. CiRCA(-. PUBLIC WORKS PAYROLL REPORTING FORM Depat-W or IW%w..l RxIA- Page of 1 NAME OF CONTRACTOR PWLC II, INC. CONTRACTORS ADDRESS LICENSE NO 8557$3 7235D QUARRY TRL NA THOUSAND PALMS CA 92276 OR SUBCONTRACTOR SPECIAUTY LICENSE NO PAYROLL NO 1-1 FOR WEEK ENDING. 03/1412021 SELF -INSURED CERTIFICATE NO PROJECT OR CONTRACT NO COLD-lf2•TREFISTUMP REMOV (41 DAY Il) (6) WORKERS' COMPENSATION POLICY NO WS05059867-00 Pe01ECTANDLOCATION III Ili I (11 11 1 T I 111 TH 1 F 1 5 1 S (7) ixl (9) DATE NETWGS PAIDFOR WEEK CIIECK NO NAME ADDRESS AND SOCIAL SECURITYNUXIBER OFEMPLOYEE ` I WORK CL.ASSIFlCATION 6 o I TOTAL HOURS IIOURLY RATE OF PAY GROSS AMOUNT EARNED DEDUCTIONS. CONTRIBUTIONS ANDPAY161NTS 08 D9 10 11 12 13 14 a1 I cEa: HOURS WORKED EACII DAY HENRtDUEZ, RUBEN F 15687 PALM DR #83 DESERT HOT SPRINGS CA 92240 TREE I MAINTENANCE I LABORER 1 S g 6 25,17 TLHS PROJECT ALL PROJECTS no TAX PICA Isar SEC.) STATE TAX SDI VACr 1RILmAv IIEALTII a WELT. PENSION 645.22 3325916 532 151.02 892.08 92.13 67.83 26.35 10.64 O.DO 0.00 0.00 FIND ADMW SUES TRATRAtNC SU SV! sAYLNrs OT11tR• Ue0VC• TN1.Ni I T O 1 0.00 0.00 0.00 0.00 0.00 49.9E 246.E6 LUNA GONZALEZ. CARLOS 66145 TTH ST DESERT HOT SPRINGS CA 92240 I TREE I MAINTENANCE I LABORER I S 0 6 27.22 THIS PROJECT ALL PROJECTS Fta. TAX FICA ISDC. SECT STATE TAX sal VACI HOLIDAY REALTII ■ WELT. pExstDN 817.84 33270 163.32 941.28 37.59 72.0E 2.54 11,30 0.00 0.00 0.00 TRAVAC. FUND ADMIN DUES TRAAL SUgiV/ SAVINGS OTHER• IEDTTELL'SC- I I O I 0.00 0.00 0.00 0.00 0.00 0.00 123.44 RAMIREZ, MARCELINO 1500 E SAN RAFAEL DR 4164 PALM SPRINGS CA 92262 I TREE I MAINTENANCE 1 tABORER I S fi 6 29A2 Tills PROJECT ALL PROJECTS FED TAX FICA tsbC. SrC1 SFATIE TAX SDI VAc/ wi-wv HEALTIt • wttr. PLNsIm 868.12 3327E 176.52 1026.68 45.33 77.03 4.33 12.08 0.00 0.06 0.00 TRALNG FUND ADW., DUES > VI SAVINGS HT11ER• TOTAL DEDUC. TIONS I o I 0,00 0.40 0.00 0.00 0.00 19.19 157.96 1 Tills PROJECT ALL PROJECTS Fib TAX FICA (SOC.SECI STATE TAX SIII VAC! 11OL1DAY IIXALTII aWELP. 1'ENISION t 5 1 TRALNC. FUND AD%M DUES SMTIRAW SAVINGS OMER• DEd1A1C_ THRts 1 O S-SIRAIGIFFTIME •tmb-R_Any other deductions, cone ibutims and/or payments whether Or not included at repaired by prevailing CERT]RCATION NIIJiT be completed I'-riw Ml Ell lNr+� 1 yO 11-MURTIM -Im determinations must be sepantely lisled Use "in shectls) irnccessary (See reverse side) %IA - STAIV IM.'MILRATY 1NMIMANLT 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 46.60 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 11, INC. WEEK ENDING PROJECT # & LOCATION 3/14/2021 COLQ-#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 8-1r2 x I I inches) 1, KR[STY SOUTH the undersigned, am the (Name — print) CONTROLLER with the authority to act for and on behalf of (Position in business) PWLC 11, INC. _ certify under penalty ofperjugF (Name of business and/or contractor) that the records or copies thereof submitted and consisting of COLQ42•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 b) way of cash, check, or whatever form to the individual or individuals named. Date, 08/05/2021 Signature: Z A'-'F-4& A public entity ma) require a stricter and/or more extensive form of certification_ JRCabfamua PUBLIC WORKS PAYROLL REPORTING FORM Dep.tum nt of IndwnAl Relmm 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 PAYROLLNO 1-1 FINAL FOR WEEKENDING 03/2112021 SELF -INSURED CERTIFICATE NO PROJECT OR CONTRACT NO COLQLORpYARD•AVE52 TREE (J) DAY ISI 16) WORKF.RSCOMPENSATIONPOLICYNO WSO5059867-00 PROJECTANOLUCATION I I I91 111 RI (3) M T W T1! F s S 17) (al I HOURLY NA.tiIC-ADDRESS AND F I WORK DATE TOTAL RATE GROSS AMOUNT NETWGS CHECK 15 15 17 1E 19 20 21 SOCIALSECURRYNUAIDER s' s CLASSIFICATION HOURS OF PAY EARNED DEDUCTIONS. CONTRIBUTIONS AND PAYMENTS PAID FOR NO OFEMPLOYEE I•-6 WEEK HOURS WORKED EACH DAY TREE TiRS ALL FED. ncA STATE sDl VArI HEALTH s�F,NsroN 715.10 3330216 HENR(QUEZ, RUBEN F I MAINTENANCE 25 t7 PROJECT PROJECTS TAX ISOC SEC) TAX IHVA171 V • WELD. 531 100.68 1006.60 114.38 76.62 33.03 12.02 0.00 0.00 0.00 15687 PALM DR #83 I LABORER S 4 DESERT HOT SPRINGS CA 92240 I TRAY1 OTAL I TRAINC FT'ND puts sU SAVINGT OTHER• DEDVC- 1 ADMIX Tuns 0.09 0.00 0.00 D.aD D.aD ss.ss 29170 1 0 I TREE TINS ALL FED. nCA STATE iUl VAC! IIEALTI t'ElaS1ON 929.34 33305 LUNA GONZALEZ. CARLOS l MAINTENANCE PROJECT PROJECTS TAX fsOC SEC.I TAX 11 Al A wELF. S 4 4 27.22 66145 7TH ST I LABORER 217.76 1088.80 55.16 83.30 7.97 13.07 0.00 0,00 0.00 DESERT HOT SPRINGS CA 92240 I TTAL TRALY 1 FUND VUES SU7NS. SAVINGS OTFIER• berbeC- I ADSILN TIONS O I 0.00 0.00 0.00 0.00 0.00 0.00 159.46 I TREE Tills ALL FED. nCA RATE SD[ VACI HEALTH IK..NstON 980.79 33306 RAMIREZ. MARCELINO I MAINTENANCE 29.42 PROJECT PROJECTS TAX IsOC SEC' TAX I{OLMAV A WELF 235.36 1176.90 63.41 88,56 10,96 13.89 0.00 0.00 0.00 15DO E SAN RAFAEL OR 0164 I LABORER S 4 q PALM SPRINGS CA 92262 I TRALNG FVNP OUTS TRAM suns. SAVLNCS OTHER• TOTAL DEDUC- I Aps1Il TIONS tT I 0.00 0.00 0.00 0.00 0.00 19.19 196.01 Tills ALL FEU. FICA RATE SDI VACI IIEAL71! PENSION I � PROJECT PROJECTS TAX Is°c ItC.l TAX NDLHIAV • WEEP. I TRALYC FVND DVLS svm SAVINGS OTHER' DxlwC - ApSIIY THINS 1 a s-sttNn[UITFnItI: YanWIt-Aayathesdeduclions,rnntributimsand/or paymmlIwitclhmornot indudtdornquired bypsevailing CERTIFICATION h111.STbecompleted r-A.1.111 ttk+2-tap O-OVi7tT15n: wage dclerminatitsna must bescpaitely listed Use eatsa shcells► ifncvssary (see severe side) SIX • STATE 01"1ILITV I NSIOANXT PUBLIC WORKS PAYROLL REPORTING FORM A-1-131 PWLC II, INC. WEEK ENDING PROJECT # & LOCATION 3/21/2021 COLQ-CORP YARD-AVE52 TREE REMOVAL/CLEAN UP (8) DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS OTHER* HENRIQUEZ, RUBEN F 50.34 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 Privacy Considerations Fold back along dotted line prior to copying for release to general public (private persons). (Paper Size then 8-1;2 r 11 inches) I KRISTY SOUTH the undersigned, am the (Name -- print) CONTROLLER with the authority to act for and on behalf of (Position in business) PWLC 11, INC. certify under penalty of perjury (Name of business and/or contractor) COLO-COMPYAMIAVE17 Met KtMOVAL{LEAN. A 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 «hich depict the payroll record(s) of the actual disbursements by way of cash, check, or whatever form to the individual or individuals named. Date, 08/05/2021 Sigenature- A public entity may require a stricter and, -'Or more extensive form of certification. Cahrtmoa PUBLIC WORKS PAYROLL REPORTING FORM or hdualrul ReWnm Page _ . or. NM1E OFCOKMACTUR PMC 11, INC. CONTRACTOR'S LICENSE NO 855783 ADDRESS 72350 QUARRY TRL 8A THOUSAND PALMS CA 92276 OR SUBCONTRACTOR SPECIALITY LICENSENO PAYROLL NO 2-1 FINAL FOR WTEK ENDING 03/21/2021 SELF -INSURED CERTIFICATE NO PROJECTOR CONTRACT NO COLA #2-TAEFISTUMP REMOV 17- NI PAY ISI (6) WORKERS COMPENSATION POLICY NO WSp5059867-00 PROJECT AND LOCATION � 1 I I 41) 12) (3) NI T W Tit F S 5 (7) IIOURLY NMIE, ADDRESS ANO r- z I WORK DATE TOTAL RATE GROSS AMOUNT NETWGS OtECK 15 16 17 1 18 19 120 121 SOCIALSEMRTTY NUNIRER ;F c C CLASSIFICATION HOURS OF PAY EARNED DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS PAID FOR NO OFEMPLOYEE qzqg 1 WEEK � S I z_ HOURS WORI:m E.ICH DAY TREE Tilts ALL rED "CA STATE III VAC) HEALTIt PLmSIOm 715.10 33302J6 HENRIQUEZ, RUBEN F 1 MAINTENANCE 8 PROJECT PROJECTS TAX ISOC SEGi TAX HOUDAY A WELF. 531 5 e 25.17 15687 PALM DR #83 1 LABORER 201.36 1006.80 114.38 76.62 33.03 12.02 0.00 0.00 0.00 DESERT HOT SPRINGS CA 92240 I YlA T1mG FVNO DUES 'SAYINGS tlT11ER• dEdU C- 1 0.00 0.00 0.00 0100 0.00 55.65 29170 I O I TREE Tills ALL FM FICA STATE SOl VACI IMALTIt YEmsinm 929.34 33305 PROJECT PROJECTS TAX JSOC.SEC.I TAX UOUIIAV A WELF LUNA GONZALEZ. CARLOS I MAINTENANCE 8 27,22 217.76 105880 55,16 83.30 7.93 13.07 0.00 0.00 0.00 66145 7TH ST I LABORER S 8 DESERT HOT SPRINGS CA 92240 I T1tA1NG i17NO nl'[.4 SU�VI 'SAYING'S Of1IER• LE�OUC_ I 0 1 0.00 0.00 0.00 0.00 0.00 0.00 159.46 I TREE Tilts ALL FEB. RCA STATE SDIVACI HEALTH PE.Ns1DN 980.79 33306 RAMIREZ, MARCELINO I MAINTENANCE 29.42 PROJECT PROJECTS TAX ISOC SEC.) TAX HOLIDAY A WILE 235.36 1176.80 63.41 88.56 10.96 13.59 0.00 0.00 0.00 1500 E SAN RAFAEL OR #164 I LABORER S 8 7 PALM SPRINGS CA 92262 1 TRAING MIND ICES T �Yl SAYINGS (ITIIER• RUC_ I ADVIN TIONS 0 I 0.00 0.00 0.00 0.00 0,00 19.19 196.01 THIS ALL I'm FICA STATE Sol VACI IETALTII IGNSION PROJECT PROJECTS TAX Ism sEG1 TAX ItnLInAY a WILF. I S I TuOu: M" DUES suKSI SAVINGS OTHER• �ur_ AMIN T1IlN4 I O s- sTNAlrltrlutE¢-nJJme-Anyotherdeductions•ronJribulionsandlorpaymenlswhetherornalncludedarrnqutredbyprevalling CERTIFICATION MUS'1'becompleted F.+-A•1,11EIN-2-1 O-oV13011,01 wage daterminalions must be scpamtdy listed Use cwa shee(s) tfneeesssry (Sae revere Hdel SIN - STAIEtySNIItJ YINStIIeANO! PUBLIC WORKS PAYROLL REPORTING FORM A-1-131 PWLC II, INC. WEEK ENDING PROJECT # & LOCATION 3/21/2021 COLA-#2-TREE/STUMP REMOVAL AVE54 (8) DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS OTHER* HENRIQUEZ, RUBEN F 50.34 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 r2 x I I inches) I KRISTY SOUTH the undersigned, am the (Name — print) CONTROLLER with the authority to act for and on behalf of (Position in business) PW_LC II, INC. certif) under penalty of perjury (Name of business and/or contractor) that the records or copies thereof submitted and consisting of COLO42-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 Nvay of cash, check, or whatever form to the individual or individuals named. Date_ 08/05/2021 signature: A public entity may require a stricter and/or more extensive form of certification.