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Home My WebLink About238650 10/28/14 ��q,f� CITY OF CARMEL, INDIANA VENDOR: 191500 /� `' ONE CIVIC SQUARE MADDOX INDUSTRIAL CONTRACTORS QWCK AMOUNT: $****37,245.64* f? ��, CARMEL, INDIANA 46032 6731 AMERICANA BLVD CHECK NUMBER: 238650 9,j��rON G�'` INDIANAPOLIS IN 46268 CHECK DATE: 10/28/14 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 609 5023990 7 37,245.64 OTHER EXPENSES L = \�� TM �'/ o Document 6702 - 1992 Application and Certificate for Payment TO OWNER: PROJECT: APPLICATION N07 Distribution to: CITY of CARMEL CARMEL WWTP FILTER ADD # 84 PERIOD TO:. 9/3.0/2014 One Civic Square OWNER ❑ CARMEL, IN 46082 CONTRACT FOR:CARMEL WWTP FILTER ADD # 84 ARCHITECT ❑ FROM CONTRACTOR: VIA ARCHITECT: CONTRACT DAT0/6/2014 MADDOX INDUSTRIAL CONTRACTORS JONES &HENRY ENGINEERS, LTD. CONTRACTOR ❑ 8731 AMERICANA BLVD 431 OHIO PIKE, SUITE 305 PROJECT NOS: 350401 / / FIELD ❑ INDIANAPOLIS, IN 46268 CINCINNATI, OH 45255 INVOICE NO: 00001245 OTHER ❑ CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, infonnation Application is made for payment,as shown bellow,in connection with the Contract. and belief the Work covered by this Application for Payment has been completed in accordance AIA Document adefoContinuation Sheet, attached. with the Contract Documents, that all amounts have been paid by the Contractor for Work for 788 300.00 Which previous Certificates for Payment were issued and payments received fiom the Owner, and 1.ORIGINAL CONTRACT SUM................................................. $ that current payment shown herein is now due. 2.NET CHANGE BY CHANGE ORDERS.............................. $ 17,831.00 CONTRACTO • MADDOX,INDUSTRIAL CONTRACTORS 3.CONTRACT SUM TO DATE(Line 1 f 2) ..................................... $ 806,131.00 By: / X� Date: —30 -ZO (4- 4.TOTAL COMPLETED&STORED TO DATE(Coleman G on G703) ...... $ 801,031.00 State of: IN 5.RETAINAGE: - County of:Marion a. 2,5 %of Completed Work Subscribed and sworn to before (Cohumns D+E on G703) $ 20,000.42 me this 310 day of b• 0 %of Stored Material (Cohrmn F on G703) $ 0.00 Notary Public: Michelle C Dunlap Total Retainage(Lines 5a+5b, or Total in Column I of G703)...... $ 20,000.42 My commission expires: 4/25/2020 6.TOTAL EARNED LESS RETAINAGE .................................... $ 781,030.58 ARCHITECT'S CERTIFICATE FOR PA � ��!., MICHELLE C t�UN6AR� (Line 4 nninus Line 5 Total) In accordance with the Contract Documents,based on •3itecxob t °n�r n� � t� i af�� 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT ...................... $ 743,784.94 this application,the Architect certifies to the Owner that£o'' �g� st� the& } � Rs lge, mfonnation and belief the Work has progressed as in' c Pt),iz giAA�i yurefri o� j f m (Line 6 firona prior Certificate) accordance with the Contract Documents, and the Con(Mool�`1s entiticAp dl ftrg �[�of the C 37 245.64 AMOUNT CERTIFIED. 8.CURRENT PAYMENT DUE ........................................:.... $ � -- 9.BALANCE TO FINISH,INCLUDING RETAINAGE AMOUNT CERTIFIED .................................'........................................... $ (Lune 3 minus Line 6) $ 25,100.42 (Attach explanation if amotint certified diers fiom the amount applied Initial all fipres on this Application and on the Continuation Sheet that are changed to conform with the amount certified.) CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHITECT: Total changes approved in previous months by Owner $ 0.00 $ 0.00 By: Date: h, —6e–!y Total approved this month $ 17 831.00 $ 0.00 This Certificate is not negotiable.The AMOUNT CERTIFIED is payable only to the Contractor TOTAL $ 17 831.00 $ 0.00 named herein.Issuance,payment and acceptance of payment are without prejudice to any rights of ,NET CHANGES by Change Order $ 17 831.00 the Owner or Contractor under this Contract. CAUTION:You should sign an original AIA Contract Document,on which this text appears in RED.An original assures that changes will not be obscured. AIA Document G702 T11—1992.Copyright @ 1953,1963,1965,1971,1978,1983 and 1992 by The American Institute of Architects.All rights reserved.WARNING:This AIA® Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIA® Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law.Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract Documents,e-mail The American Institute of Architects'legal counsel,copyright@aia.org. 010711AC044 Prescribed by State Board of Accounts Form No.301 (Rev.1995) ACCOUNTS PAYABLE VOUCHER TO ADDRESS Invoice Date Invoice Number Item Amount I herebycertify that the attached invoice(s), or bills , is (are) true and correct and that the materials or services fYO ( itemized thereon for which charge is made were ordered and received except Mo. Day Yr. Signature Title 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. JILIZ, Mo. Day Yr. ficer Title Voucher No. Warrant No. ACCOUNTS PAYABLE DETAILED ACCOUNTS MUNICIPAL WATER DEPT. ACCT. CARMEL, INDIANA No. �IAc�C�b� 12r,�us f Favor CoNf�l9� Total Amount of Voucher $ Deductions 72` 5 /L 0 -7-/05a . Amount of Warrant $ Month of Yr Acct. VOUCHER RECORD No. Source of Supply Water Treatment Transmission and Dist. Customer Accounts Administrative and General Operation-Maintenance Utility Plant in Service Constr.Work in Progress Materials and Supplies i Customers Deposits Total r Allowed Board of Control Filed Official Title BOYCE FORMS•SYSTEMS 1-800-382-8702 325