Form CEM-2505 "Owner-Operator Listing" - California

What Is Form CEM-2505?

This is a legal form that was released by the California Department of Transportation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2015;
  • The latest edition provided by the California Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CEM-2505 by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
ADA Notice
OWNER-OPERATOR LISTING
For individuals with sensory disabilities, this document is available in alternate
CEM-2505 (REV 07/2015)
formats. For information, call (916) 445-1233, TTY 711, or write to Records
and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
NAME OF CONTRACTOR EMPLOYING OWNER OPERATOR(S)
PUBLIC WORKS CONTRACTOR REGISTRATION NUMBER
ADDRESS
PAYROLL NO.
FOR WEEK ENDING
PROJECT AND LOCATION
CONTRACT NO.
DAY AND DATE
NAME, ADDRESS, SOCIAL SECURITY NO. AND
DESCRIPTION
TRUCK CAL T NO.
TOTAL
HOURLY
GROSS
WORK
CHECK
ST
CONTRACTORS LICENSE NO. OF OWNER-
OF
AND/OR EQUIP.
WEEKLY
RATE OF
PAYMENT
CLASSIFICATION
NO.
OR
OPERATOR (IF ANY)
EQUIPMENT
LICENSE NO.
HOURS
PAY
EARNED
OT
S
O
S
O
S
O
S
O
S
O
S
O
S
O
S
O
NOTE: CERTIFICATION WILL BE ACCEPTED ONLY FROM THE CONTRACTOR EMPLOYING THE OWNER
OPERATOR: IT WILL NOT BE ACCEPTED FROM THE OWNER OPERATOR HIM / HERSELF.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
ADA Notice
OWNER-OPERATOR LISTING
For individuals with sensory disabilities, this document is available in alternate
CEM-2505 (REV 07/2015)
formats. For information, call (916) 445-1233, TTY 711, or write to Records
and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
NAME OF CONTRACTOR EMPLOYING OWNER OPERATOR(S)
PUBLIC WORKS CONTRACTOR REGISTRATION NUMBER
ADDRESS
PAYROLL NO.
FOR WEEK ENDING
PROJECT AND LOCATION
CONTRACT NO.
DAY AND DATE
NAME, ADDRESS, SOCIAL SECURITY NO. AND
DESCRIPTION
TRUCK CAL T NO.
TOTAL
HOURLY
GROSS
WORK
CHECK
ST
CONTRACTORS LICENSE NO. OF OWNER-
OF
AND/OR EQUIP.
WEEKLY
RATE OF
PAYMENT
CLASSIFICATION
NO.
OR
OPERATOR (IF ANY)
EQUIPMENT
LICENSE NO.
HOURS
PAY
EARNED
OT
S
O
S
O
S
O
S
O
S
O
S
O
S
O
S
O
NOTE: CERTIFICATION WILL BE ACCEPTED ONLY FROM THE CONTRACTOR EMPLOYING THE OWNER
OPERATOR: IT WILL NOT BE ACCEPTED FROM THE OWNER OPERATOR HIM / HERSELF.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
OWNER-OPERATOR LISTING
CEM-2505 (REV 07/2015)
Date
do hereby state:
(Name of signatory party)
(Title)
(1) That I pay or supervise the payment of the persons reported on this form as Owner-operators by
(Contractor or subcontractor)
on the
, that during the payroll period commencing on the
day of
(Building or work)
and ending the
day of
,
, all persons working on said project have been paid the
full weekly sums earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said
from the full weekly sums earned by any person and that no deductions have
(Contractor or subcontractor)
have been made either directly or indirectly from the full sums earned by any person, other than permissible deductions, as
described here:
(2) That any payrolls or listings or 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.
(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 or listings 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 or listings has been paid as indicated on the payroll or listings 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
Remarks:
NAME AND TITLE
SIGNATURE
On federally-funded projects, permissible deductions are defined in regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland
Act, as amended (48 Stat. 948 63 Stat. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. 276c).
Also, 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 231 of Title 31 of the United States Code).
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