PUBLIC WORKS PAYROLL REPORTING FORM

California Department of PUBLIC WORKS PAYROLL REPORTING form . Industrial Relations Page _____ of _____. NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO.: ADDRESS: OR SUBCONTRACTOR: SPECIALITY LICENSE NO.: PAYROLL NO.: FOR WEEK ENDING: SELF-INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.: (4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: PROJECT AND LOCATION: (9). (1) (2) (3) M T W TH F S S (7) (8). HOURLY. DATE. NO. OF WITH- NAME, ADDRESS AND work TOTAL RATE GROSS AMOUNT. EXEMPTIONS. NET WGS CHECK. SOCIAL SECURITY NUMBER CLASSIFICATION HOURS OF PAY EARNED DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS PAID FOR NO.

payroll no.: for week ending: self-insured certificate no.: project or contract no.: (4) day (5) total che hours (6) hourly rate of pay workers' compensation policy no.: project and location: (2) h-wit ng tio of di pem no. hol ex (9) m t ; w f s s date (1) name, address and social security number of …

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