2016-08 Sky Construction, Inc. Non-Performance WE 2020-08-29STATEMENT OF NON-PERFORMANCE
Information recorded on this form can be for one or more weeks, but not more than four
week of information on one form. For example, if information exceeds four weeks, then a
separate form is required for the 5th week up to the 8`h week.
Payroll Number(s): Date:
I do hereby under penalty of perjury, state that no person(s) were employed on the construction
of the below project.
Project Name: Project Number:
UC3
During the payroll eriod s
commencing Date: Ending
cDate:
-
Qcao
S gn ture of Authoriz erson: Title:
s) dLr-*,-
** All shaded areas must be completed before submittal.
Public Works Certified Payroll Reporting Form
Certification under penalty of perjury:
1, ROBERTA CRNCIC, the undersigned, am the PRESIDENT (position in business) with the authority to act for and on behalf of SKY CONSTRUCTION SERVICES INC (name of business and/or contractor),
certify under penalty of perjury that the records or copies thereof submitted and consisting of certified payroll records for the week ending 2020-08-29 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. I certify this on 2020-08-30."
Contractor Name: SKY CONSTRUCTION SERVICES, INC Contractor PWCR: 1000046770 License Type: CSLB License Number 1026204
Address: 4 YORKSHIRE CT, RANCHO MIRAGE, CA 92270 FEIN: 814976305 Contractor Email: INFO@SKYCONSTRUCTIONSERViCES.COM
Insurance Number: WSA5056129
Awarding Body: THE CITY OF LA QUINTA DIR Project ID: 300347 Project Name: LA QUINTA SILVERROCK PARK VENUE
Contract With: URBAN HABITAT County: RIVERSIDE Location Description:
Payroll #: 4 - 0 Ctr Payroll M 4 Week Ending: 08/29/2020 `/' Statement of Non -Performance? Final payroll for this project?
Public works certified Payroll Reporting Form 08/30/2020 - Page I