STATEMENT OF NO WORK PERFORMED	

Company Name and Address:

                                                                 

 

Payroll Week No.                                    

I hereby certify that no employee worked on the construction site of the

                                                                                               during the period commencing	

 on the            day  of                                             ,                  and ending on the              day of
   
       		         ,	              .

				                                           
Signature of Authorized Person				Date

                                                   
Title