2025-05 - 2505 23 StatewidePAYROLL REPORTING FORM Page 1 of 1
NAME OF CONTRACTOR OR SUBCONTRACTOR
Statewide Contracting of America
CONTRACTOR'S LICENSE NO: N/A
SPECIALITY LICENSE NO:
ADDRESS
45945 Warm Springs Blvd , FREMONT, CA 94539
PAYROLL NO.
3
FOR WEEK ENDING
05/24/2025
SELF-INSURED CERTIFICATE NO:
WORKER'S COMPENSATION POLICY NO:
PROJECT OR CONTRACT NO: 20240543108
PROJECT AND LOCATION: The Rise at Vallco Horizontal Ph1A / 10123 N Wolfe
Rd, Cupertino, CA
(1)
NAME, ADDRESS, AND
SOCIAL SECURITY
NUMBER
OF WORKER
(2)
NO
O
F
W
I
T
H
-
HO
L
D
I
N
G
EX
E
M
P
T
I
O
N
S
(3)
WORK
CLASSIFICATION
ST
/
O
T
/
D
T
/
H
T
(4) DAY AND DATE (5)
TOTAL
HOURS
(6)
RATE
OF PAY
CASH
FRINGE
(7)
GROSS
AMOUNT
EARNED
(THIS / ALL)
(8)
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
(9)
NET WAGES
PAID FOR
WEEK
(10)
Check No.
/DateSunMonTueWedThuFriSat
18 19 20 21 22 23 24
HOURS WORKED EACH DAY
Rafael Castro Vega
16 E 20th St
TRACY, CA 95376
xxx-xx-8315
S/0
CA 2024-1
Journeyman
Santa Clara
Teamster
Group 3
S 8.00 8.00 8.00 8.00 6.00 38.00 42.14 1,854.16
2,812.50
FICA FED
TAX
STATE
TAX / LT SDI VAC
HOLIDAY
HEALTH
& WELF PENSION
1,852.01 954936513
05/30/2025O1.00 1.00 1.00 1.00 4.00 63.21
215.16 507.90 203.68 33.75 13.32 559.44 5.25 220.50
TRAING OTHER
REIMB.DUES TRAV
SUBS
OTHER
FRINGE
OTHER
DEDS
TOTAL
DEDUCTS
D 1.20 50.40 14.97 628.74 960.49
Joel Reyes Diego
5518 Judith St Apt 4
SAN JOSE, CA 95123
xxx-xx-4902
S/2
CA 2024-1
Journeyman
Santa Clara
Teamster
Group 3
S 8.00 8.00 42.14 400.33
2,862.73
FICA FED
TAX
STATE
TAX / LT SDI VAC
HOLIDAY
HEALTH
& WELF PENSION
2,164.52 954936494
05/30/2025O1.00 1.00 63.21
219.00 325.45 119.41 34.35 13.32 119.88 5.25 47.25
TRAING OTHER
REIMB.DUES TRAV
SUBS
OTHER
FRINGE
OTHER
DEDS
TOTAL
DEDUCTS
D 1.20 10.80 14.97 134.73 698.21
Enrique Romero
801 Paula St
SAN JOSE, CA 95116
xxx-xx-3817
S/0
CA 2024-1
Journeyman
Santa Clara
Teamster
Group 3
S 8.00 8.00 8.00 24.00 42.14 1,200.99
2,676.79
FICA FED
TAX
STATE
TAX / LT SDI VAC
HOLIDAY
HEALTH
& WELF PENSION
1,814.47 911934198
05/30/2025O1.00 1.00 1.00 3.00 63.21
204.77 435.64 189.79 32.12 13.32 359.64 5.25 141.75
TRAING OTHER
REIMB.DUES TRAV
SUBS
OTHER
FRINGE
OTHER
DEDS
TOTAL
DEDUCTS
D 1.20 32.40 14.97 404.19 862.32
S FICA FED
TAX
STATE
TAX / LT SDI VAC
HOLIDAY
HEALTH
& WELF PENSION
O
TRAING OTHER
REIMB.DUES TRAV
SUBS
OTHER
FRINGE
OTHER
DEDS
TOTAL
DEDUCTS
D
S = STRAIGHT TIME
O = OVERTIME
D = DOUBLETIME
SDI = STATE DISABILITY INSURANCE
OTHER-Any other deductions and/or payments whether or not included orrequired by prevailing wage determinations must be separately listed.Use extra sheet(s) if
necessary
CERTIFICATION MUST be completed
(See Statement of Compliance)
Printed Date: 6/27/2025 Page 1 of 2
STATE OF CALIFORNIA
STATEMENT OF COMPLIANCE
Date: 6/10/2025
Darin Bawks Operations Manager do hereby certify under penalty of perjury:
(Name of Signatory Party)(Title)
(1) That I pay or supervise the payment of the persons reported on the Certified Payroll Report by
Statewide Contracting of America on the The Rise at Vallco Horizontal Ph1A
(Contract/Subcontract: 20240543108) : that during the payroll period
(Contractor or Subcontractor) (Building or Work)
commencing on the 18th day of May 2025 , and ending the 24th day of May 2025 ,
all persons employed on said project have been paid and full weekly wages earned,that no rebates have
been or will be made either directly or indirectly to or on behalf of said
Statewide Contracting of America from the full weekly sums earned by any person
(Contractor or Subcontractor)
and that no deductions have been made either directly or indirectly from the full sums earned by any person, other than permissible deductions, as described
below:
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or
mechanics contained therein are not less than the applicable wage rates contained in any wage determination Incorporated into the contract; that the
classifications set forth therein for each laborer or mechanic conform with the work he performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship
agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are
registered with the the Bureau of Apprentice and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits
as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section
4(c) below.,
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum
of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section
4(c) below.
(c) EXCEPTIONS
Exception (craft)EXPLANATION
Teamsters $14.97 other cash fringes are paid directly to employee
paychecks
REMARKS:
NAME AND TITLE SIGNATURE
Darin Bawks
Operations Manager
06/10/2025 13:35:54
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR
CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 3729 OF TITLE 31 OF THE UNITED STATES CODE
Signed under penalty of perjury
Printed Date: 6/27/2025 Page 2 of 2