ADDENDUM 1 TO BID DOCUMENTS FOR ... - Port Canaveral

CANAVERAL HARBOR 44 FOOT CHANNEL PROJECT – PACKAGE 1PUR-ITB-13-5/CN1-8-10-12-014AForm-3On-Site Payroll ReportNumbers reference attached instructionsPage 1 of 2CANAVERAL PORT AUTHORITYPROJECTComplete a Separate Form for Each Subcontract with Sponsor.Your report is due not later than the 10 th day of each month. You can submit via email, fax, or mail. Original copy not required.Delay in providing this report may result in payments being withheld.A. Report IdentificationPeriod Beginning:1Period Ending:2Year:3Contractor Name:Contract is with:Contract #:456B. Activity Report1aStatebWorkers’CompensationClass CodecWork DescriptiondMan-HourseGross PayrollfReportable Payroll *TOTALS:2 3 4*Do not include premium (excess) overtime wages, use straight time wage rates only.g. Total Progress Payments forthe Month:$**************************************TOTAL PROGRESS PAYMENTS SHOULD INCLUDE ALL CHANGE ORDERS********************************C. Signature Block :I verify the information presented above and attachments are correct:Name:(please print)Title:Date:Signature: CHECK IF THIS IS YOUR LAST PAYROLL REPORT. COMPLETE AN INSURANCE OFFICE OF AMERICA FORM-4 “NOTICE OF WORK COMPLETION”AND INCLUDE WITH THIS PAYROLL REPORT.Mail to: OCIP Administrator Fax to: Shannon FugateInsurance Office of AmericaInsurance Office of America4020-B Plank Road Fax: (800) 568-2991Fredericksburg, VA 22407 Phone: (540) 785-7575Email: Shannon.Fugate@ioausa.com2012-10/436743 00 73 16.11 - 7 ADDENDUM #1