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MASSACHUSETTS WEEKLY CERTIFIED PAYROLL REPORT FORM <br /> Company Name: Address: Phone No: Payroll No: <br /> 476 Main Street <br /> MU ANDA'S EXCAVATING 508-432-2050 <br /> Harwich,MA 02645 <br /> Employers Signature: Title: Contract No: Tax Payer ID No. Work Week Ending: <br /> Owner 04-345-0910 04/16/11 <br /> Awarding Authority: Public Works Project Name: Public Works Project Location: Min Wage Rate Sheet No. <br /> TOWN OF MASHPEE MD.RAULIC - 360 ASHER'S PATH <br /> MASHPEE TRANSFER STATION MASHPEE,MA <br /> General/Prime Contractors Name: Subcontractor's Name: <br /> HOURS WORKED EMPLOYER CONTRIBUTIONS <br /> Employee Name&Address Work OSHA 10 (A) (B) (C) (D) (E) (F) (G) [A*F] <br /> Classification Cards Total Hourly Base Health& Pension Supp [B+C+D+E] Weekly <br /> S M T W T F S Hours Wage Welfare Unemp Hourly Total <br /> Warren Miranda Total Wage <br /> 40 Flax St. Backhoe <br /> Dennis MA 02638 Operator Y 1 1 2 1 3 1 2.5 1 7.5 $60.98 $0.00 1 $0.00 $0.00 $60.98 $457.35 <br /> Joseph Perry <br /> 468 Main St. <br /> Harwich MA 02645 Laborer Y 3 2.5 5.5 $45.75 $0.00 $0.00 $0.00 $45.75 $251.63 <br /> Mike Mendes <br /> 96 Cammett Rd. <br /> Marston Mills,MA 02648 Laborer Y 1 2.5 1 2.5 $45.75 $0.00 $0.00 $0.00 $45.75 $114.38 <br /> 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 <br /> 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 <br /> 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 <br /> 0 $0.00 1 $0.00 1 $0.00 I $0.00 $0.00 $0.00 <br /> NOTE:Pursuant to MGL Ch 149 s.27B,every contractor and subcontractor is required to submit a"true and accurate"copy of their weekly payroll records directly to the awarding authority.Failure to comply may result in the <br /> commencement of a criminal action or the issuance of a civil citation. <br /> Date received by awarding authority <br /> Page 1 of 1 <br />