238874 11/05/14 CITY OF CARMEL, INDIANA VENDOR: 00351429
[i
ONE CIVIC SQUARE M.K. BETTS ENGINEERING INC CHECK AMOUNT: $""`12,305.00'
CARMEL, INDIANA 46032 PO BOX 2533 CHECK NUMBER: 238874
ANDERSON IN 46018 CHECK DATE: 11/06/14
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
609 5023990 9 12,305.00 OTHER EXPENSES
1
APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT 0702 '(Instructions on reverse side) PAGE ONE OF PAGES
-TO (OWNER): City of Carmel 1 PROJECT. Well'30 APPLICATION NO: Nine (!9) Distribution to:
One Civic..-Square Contract No. 82 . .Retainage El OWNER
Carmel, IN 46032 PERIOD TO: 09/26/14 Q ARCHITECT
G CONTRACTOR
FROM (CONTRACTOR): VIA (ARCHITECT): • ARCHITECT'S C
M. K. Betts Engineering PROJECT NO: L
& Contracting, Inc.
CONTRACT FOR: Invoice.No. 14-110.09 Ret. CONTRACT DATE:
Application is made for Payment,=as shown below, in connection with the Contract..
CONTRACTORS APPLICATION FOR. PAYMENT Continuation Sheet, AIA Document G703, is attached.
CHANCE ORDER SUMMARY 1. ORIGINAL CONTRACT SUM ........ 246 100.00
I 2. Net change b Chane Orders • .............. ..... $ 1 6,983.40
Change Orders approved m ADDITIONS DEDUCTIONS g y g 253 083.40
previous months by Owner 3. CONTRACT SUM TO DATE (Line 1 =2) .............. $ 1
TOTAL 4. TOTAL COMPLETED &STORED TO DATE..........,, $ 253,083.40
Approved this Month (Column G on G703)
Number Date Approved
5. RETAINAGE:
C0��1 + $8,733.40 – $1,750.00
a._ % of Completed Work $
(Column D+E on G703)
b. — % of Stored Material $
(Column F on G703)
Total Retainage (Line 5a+Sb or
TOTALS I + $8-733..40 – $1,750.00 Total in Column I of G703) ..................... $ –0–
Net chan e by Chane Orders + $6,983.40 6. TOTAL EARNED LESS RETAINAGE ................... $ 2533,083.40
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
completed in accordance with the Contract Documents,that all amounts have been PAYMENT (Line 6 from prior Certificate)......... g 240,778.40
aid by the Contractor for Work for which previous.Certificates for Payment were 12,305.00
P P y 8. CURRENT PAYMENT DUE .......................... 3 i
{ issued and payments received from the Owner, and that current payment shown 9. BALANCE TO FINISH, PLUS RETAINAGE............. $ –0–
herein is now due.
(Line 3 less Line 6)
State of: Indiana County of: Madison
CONTRACTOR: M. K. Betts Engineering & Contracting, Inc., i
Subscribed and sworn to before me this 26th day of Sept. '2014
Notary Publie:e..�.��
Bv: Date: _ Sept. 26, 2014 My-Commission expires: October 28 , 2015 .
i
ARCHITECT'S CERTIFICATE FOR PAYMENT AMOUNT CERTIFIED........ ........................ $
(Attach explanation if amount certified differs from the amount applied for.)
In accordance with the Contract Documents, based on on-site observations and the
data comprising the above application,the Architect certifies to the Owner that to the ARCHITECT:
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 Certificate 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 Ithis Contract.
AIA nnf 11mrN7.r7m•a7D11!'A7 nki Amn!'LOTIel!,y[
VOUCHER# 142205 WARRANT# ALLOWED
351429
IN SUM OF $
M.K. BETTS ENGINEERING & CONTRP
P.O. Box 2533
Anderson, IN 46018
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
9 07-1052-12 $12,305.00
i
CONuek'o r✓
I
Voucher Total $12,305.00
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 10/29/2014
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
10/29/201, 9 $12,305.00
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
Date fficer