Higgins way certified pay 10-24-20WEEKLYPAYROLLRECORDSREPORT
& STATEMENT OF COMPLIANCE
In accordance with Massachusetts General Law c . 149 , §27B, a true and accurate record must be
kept of all persons employed on the public works project for which the enclosed rates have been
provided . A Payroll Form is available from the Department of Labor Standards (DLS) at
www.mass.gov/dols/pw and includes all the information required to be kept by law. Every contractor
or subcontractor is required to keep these records and preserve them for a period of three years from
the date of completion of the contract.
On a weekly basis , every contractor and subcontractor is required to submit a certified copy of
their weekly payroll records to the awarding authority; this includes the payroll forms and the
Statement of Compliance form . The certified payroll records must be submitted either by regular mail
or by e-mail to the awarding authority. Once collected, the awarding authority is required to preserve
those records for three years from the date of completion of the project.
Each such contractor and subcontractor shall furnish weekly and within 15 days after completion
of its portion of the work, to the awarding authority directly by first-class mail or e-mail, a statement,
executed by the contractor, subcontractor or by any authorizex officer thereof who supervised the
payment of wages , this form, accompanied by their payroll :
STATEMENT OF COMPLIANCE
Date: 10/28 /2020
l , ______ ..aaB=r=en=d=a=Am-=aa=en=t _____ _ President
(Name of signatory party) (Title)
do hereby state:
That I pay or supervise the payment of the persons employed by u ·
• · H\(\-< f\ ~ W 1•,i
Clayton D. Davenport Trucking, Inc . on the Install two catch basins and pipes
(Contractor, subcontractor or public body) (Building or proj ect)
and that all mechanics and apprentices , teamsters, chauffeurs and laborers employed on
said project have been paid in accordance with wages determined under the provisions
of sections twenty-six and twenty-seven of chapter one hundred and forty nine of the
General Laws.
Title President
05/14
MASSACHUSETTS WEEKLY CERTIFIED PAYROLL REPORT FORM .,,~2_t;?'f,l l."~ 1~· ·,~,
Comoanv's Name: Address: Phone No.: Pavroll No.: -;;,, '.~
,1CJ• :..· Clayton D . Davenport Trucking, Inc. 130 Colrain Street 413-774-2080 '(""' ~'r,,• 1 ~~Yi#' Greenfield , MA 01301
F'mnlover Sianature: Title: Contract No: Tax Paver ID No. Work Week Endina:
\ =\ A , r ~ It-"' \~"'~ President Higgins Way 04-3400782 10/24/2020
Subdivion
Awardlnn Authoritv's Name: Public Works Proiect Name: Publlc Works Proiect Location: Min . Waae Rate Sheet Number
City of Northampton Higgins Way Subdivision Higgins Way, Northampton, MA
20201001-008
General / Prime Contractor's Name: Subcontractor's Name: "Emolover" Hourlv Frinae Benefit Contributions
Clayton D. Davenport Trucking, Inc.
[B+C+D+E] [Ax F]
Project
Hours Hourly Health & ERISA Supp . Total Hourly Project Gross
Employee is Appr. Hours Worked (A) Base Welfare Pension Unemp . Prev. Wage Wages (G)
Employee Name & Complete Work OSHA10 Rate Wage Insurance Plan Check No.
Classification: Certified(?) (%) All Other Total Gross Address Su Mo Tu We Th Fr Sa Hours (B) (C) (D) (E) (F) Wages (H)
Brian S Meunier Foreman (Kl 0 2 8 8 3 0 21 0.00
216 Lower Road 0.00 0.00 0.00 0.00 0,00 # Deerfieldf, MA 01342
0.00 DD102920
Jacob D Davenport Owner Operator 0 2 8 8 8 0 26 0.00
228 South Shelburne Road (Kl 0.00 0.00 0.00 0.00 0.00 # Greenfield, MA 01301
0.00 D0102920
Jeremy J Durant Laborer (Heavy (Kl 0 2 8 8 8 0 26 1381,38
337 Pine Nook Road & Highway) 51.70 1.23 0.00 0.20 53 .13 # Deerfield, MA 01342 DD102920
Jay McCarthy Laborer (Heavy (Kl 0 2 8 8 8 0 26 1381 .38
51 Norwood Street & Highway) 45.44 7.49 0,00 0.20 53.13 Greenfield, MA 01301
•
•
YES I I NO I I Are all apprentice employees identified above currently registered with the MA DLS's Division of Apprentice Standards?
For all apprenticies performing work during the reporting period, attach a copy of the apprentice identification card issued
by the Massachusetts Department of Labor Standards I Divison of Apprentice Standards.
No apprentices are identified above Q
NOTE: Pursuant to MGL c. 149 s.27B, every contractor and subcontractor is required to submit a true and accurate copy of their certified weekly payroll records to the awarding
authority by first-class mail or e-mail. In addition, each weekly payroll must be accompanied by a statement of compliance signed by the employer. Failure to comply may
result in the commencement of a criminal action or the issuance of a civil citation.
Date received by awarding authority
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