233539 06/11/14 CITY OF CARMEL, INDIANA VENDOR: 00351429
ONE CIVIC SQUARE M.K. BETTS ENGINEERING INC CHECK AMOUNT: $*****1,050.00*
s �a CARMEL, INDIANA 46032 PO BOX 2533 CHECK NUMBER: 233539
ANDERSON IN 46018 CHECK DATE: 06/11/14
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
609 5023990 4 1,050.00 OTHER EXPENSES
APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT 6702 '(Instructions on reverse side) PACE ONE OF PAGES
-TO (OWNER): City of Carmel PROJECT: Plant 4 Chemical Feed APPLICATION NO:Four (4) Distribution to:
One civic Square Contract No. 83 D OWNER
Carmel, IN 46032: PERIOD TO: 05/31/14 C ARCHITECT
G CONTRACTOR
FROM (CONTRACTOR): VIA (ARCHITECT): • ARCHITECT'S c:--
M. K. Betts Engineering PROJECT NO: C
& Contracting, Inc.
I
CONTRACT FOR: Invoice. No. 14-111.04 CONTRACT DATE:
CONTRACTOR'S APPLICATION FOR. PAYMENT Continuation aSh
eet,et,AIA Document G703for Payment,as n'battachedconnection with the Contract..
CHANCE ORDER SUMMARY 1. ORIGINAL CONTRACT SUM ...................... .$ 100,900.00
Change Orders approved in ADDITIONS DEDUCTIONS 2. Net change by Change Orders ....................... $ —0—
Previous months by Owner 3. CONTRACT SUM TO DATE (Line 1=2).............. $ 100.900.00
TOTAL 4. TOTAL COMPLETED &STORED TO DATE............ $ 100.900.00
Approved this Month (Column G on G703)
Number Date Approved 5. RETAINAGE:
a. 5 % of Completed Work $ 5,045.00
(Column D+E on G703)
b.L % of Stored Material $ —0—
(Column.F on G703)
Total Retainage (Line 5a+5b or
TOTALS Total in Column I of G703) ..................... $ 5,045.00
Net than e by Chane Orders 6. TOTAL EARNED LESS RETAINAGE ................... $ 95,855.00
The undersigned Contractor certifies that-to the•best of the Contractor's knowledge, •(Line 4 less Line 5 Total)
information and belief the Work covered by this Application for Payment has been 7. LESS PREVIOUS CERTIFICATES FOR 94,805.00
completed in accordance with the Contract Documents, that all amounts have been PAYMENT (Line 6 from prior Certificate)......... $ 1,050.00
paid by the Contractor for Work for which previous.Certificates for Payment were 8. CURRENT PAYMENT DUE .......................... $
issued and payments received from the Owner; and that current payment shown 9, BALANCE TO FINISH, PLUS RETAINAGE............. $ 5,045.00
herein is now due. (Line 3 less Line 6)
CONTRACTOR: M. K. Betts Engineering & Contracting, Inc.. State of: Indiana County of: Madison
Subscribed and sworn to before me this 31st day of May 2014
Notary Public: '�
By: Date: May 31, 2014My-Commission expires: October 28 , 2015 .
ARCHITECT'S CERTIFICATE FOR PAYMENT AMOUNT CERTIFIED................................. $
(Attach explanation if amo t certified differs from the amount applied foal
In accordance with the Contract Documents,based on on-site observations and the ARCHITECT:
data comprising the above application,the Architect certifies to the Owner that to the / ���/
best of the Architect's knowledge,information and belief the Work has progressed as gv; Date: (�
indicated,the quality of the Work is in accordance with the Contract Documents,and This Certit'ca a is not negotiable. The AMOUNT CERTIFIED is payable only to the-
the Contractor is entitled to payment of the AMOUNT CERTIFIED. Contractcr,named herein. Issuance,payment and acceptance of payment are without
prejudice to any rights of the Owner or Contractor under this Contract.
AIA r%nr•IIMCAIT.rT.YI.eoo„r•.r,r..i •..n.-.nr,r.�.T ••••••••..._..._
VOUCHER # 135277 WARRANT # ALLOWED
351429 IN SUM OF $
M.K. BETTS ENGINEERING & CONTRA
P.O. Box 2533
Anderson, IN 46018
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
I' I
4 07-1052-15 $1,050.00
C 0 N�Y�LtrC7/�
� I
I
Voucher Total $1,050.00
Cost distribution ledger classification if
claim paid under vehicle highway fund
Prescribed by State Board of Accounts City Form No.201 (Rev 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show, kind of service, where
performed, dates of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
351429
M.K. BETTS ENGINEERING &CONTRACTING Purchase Order No.
P.O. Box 2533 Terms
Anderson, IN 46018 Due Date 6/5/2014
Invoice Invoice Description
Date Number (or note attached invoices) or bill(s)) Amount
6/5/2014 4 $1,050.00
I hereby certify that the attached invoice(s), or bill(s) is(are)true and
correct and I have audited same in accordance with IC 5-11-10-1.6
II
Date Officer