HomeMy WebLinkAbout250587 10/21/15 CITY OF CARMEL, INDIANA VENDOR: 367130
;; ® ONE CIVIC SQUARE BEN HUR CONSTRUCTION CO CHECK AMOUNT: $****55,000.00*
a° CARMEL, INDIANA 46032 PO BOX 22345 CHECK NUMBER: 250587
ay o, INDIANAPOLIS IN 46222 CHECK DATE: 10/21/15
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DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
902 4460807 33126 1 55,000.00 RETROFIT PALLADIUM DO
APPLICATION AND CERTIFICATE FOR PAYMENT Invoice #: 22200
To Owner: Carmel Redevelopment Commission Project: 21131-Carmel Performing Arts Center Application No.: 1 Distribution to:
30 W. Main Street-Suite 220 Application Date: 101112015 Owner
Q Architect
Carmel, IN 46032 Period To: Contractor
Q
From Contractor: Ben Hur Construction Co. Via Architect: Q
3783 Rider Trail South Project Nos:
Earth City, MO 63045
Contract For: Contract Date:
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge,
information,and belief,the work covered by this Application for Payment has been completed
Application is made for payment,as shown below,in connection with the Contract in accordance with the Contract Documents.That all amounts have been paid by the Contractor
Continuation Sheet is attached. for Work for which previous Certificates for Payment were issued and payments received from
the Owner,and that current payment shown herein is now due.
1. Original Contract Sum . . . . . . . . . . . . . . . . . . . . . . . . $55,000.00
2. Net Change By Change Order . . . . . . . . . . . . . . . . . . . . $0.00 CONTRACTOR: Ben Hur C]Dc0.
3. Contract Sum To Date . . . . . . . . . . . . . . . . . . . . . . . . . . $55,000.00
4.Total Completed and Stored To Date. . . . . . . . . . . . . . . $55,000.00 By: "lk-- Date: 1 `
5. Retainage:
•`z;T'E'��•, JENNIFER ARNOLD-BULL�p DICK
a. 0,�°/u of Completed Work State of: I a •••°''';Notary Public, State of Ir;94'd1S6 f:$0.00 Subscribed and swom to befoeq�z tRl�w'': c Hendricks Count0ayof
b. 0.00%of Stored Material $0.00 Notary Public: SEAQ•: Commission N 656489
M Commission expires- i /,,ouN� My Commission Expires
My p ,,,,,,���` August 05, 2022
Total Retainage . . . . . . . . . . . . . . . . . . . . . . . . . . . $0.00
6.Total Earned Less Retainage . . . . . . . . . . . . . . . . . . . $55,000.00 ARCHITECT'S CERTIFICATE FOR PAYMENT
In accordance with the Contract Documents,based on on-site observations and the data
7. Less Previous Certificates For Payments. . . . . . . . . . comprising the above application,the Architect certifies to the Owner that to the best of the
$0.00 Architect's knowledge,information,and belief,the Work has progressed as indicated,
8. Current Payment Due . . . . . . . . . . . . . . . . . . . . . . . . . $55,000.00 the quality of the Work is in accordance with the Contract Documents,and the Contractor
is entitled to payment of the AMOUNT CERTIFIED.
9. Balance To Finish, Plus Retainage . . . . . . . . . . . . . . $0.00
AMOUNT CERTIFIED $ 55,000.00
(Attach explanation if amount certified differs from the amount applied.Initial all figures on this Application and on the
Continuation Sheet that are changed to conform with the amount certified.)
CHANGE ORDER SUMMARY Additions Deductions
Total changes approved
in previous months by Owner $0.00 $0.00 ARCHITECT:
Total Approved this Month $0.00 $0.00 By: Date:
TOTALS $0.00 $0.00 This Certificate is not negotiable.The AMOUNT CERTIFIED is payable only to the
Contractor named herein.Issuance,payment,and acceptance of payment are without
Net Changes By Change Order $0.00 prejudice to any rights of the Owner or Contractor under this Contract.
CONTINUATION SHEET Page 2 of
Application and Certification for Payment,containing Application No. : 1
Contractor's signed certification is attached. Application Date: 10101/15
In tabulations below,amounts are stated to the nearest dollar.
Use Column I on Contracts where variable retainage for line items may apply. From
To:
Invoice#: 22200 Contract: 21131-Carmel Performing Arts Center Architect's Project No.:
_A B C D E F _ G H 1
Item Description of Work Scheduled Work Completed 4 Materials Total % Balance Retainage
No. Value From Previous This Period Presently Completed (G!C) To Finish
Application In Place Stored and Stored (C-G)
(D+E) To Date
(Not in D or E) (D+E+F)
10 Carmel Performing Arts Center 55,000.00 0.00 55,000.00 0.00 55,000.00 100.00% 0.00
I
I
I
I
i
Grand Totals 55,000.00 0.00; 55,000.00 0.00 55,000.00 100.00% 0.00 0.00
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.201(Rev.1995)
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Fen �ur Corl3fru(4 lah Co, Purchase Order No.
'570 812 TrtJ SAa-'h Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
- — I ' rn a me r e a•r i✓or'1< SS `'a
Total 95;
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accor-
dance with IC 5-11-10-1.6.
, 20-
Clerk-Treasurer
20Clerk-Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
—Ben 16r �onS�rur�'In �o, IN SUM OF $
'37Y3 fli�e r Tial I Sou h
F&A (i+ A) 004
$ ss. 600,Qb
ON ACCOUNT OF APPROPRIATION FOR
(64 902 Z
Board Members
PO#or INVOICE NO. ACCT#/TITLE AMOUNT
DEPT.# I hereby certify that the attached invoice(s),
3 2 44 d 007 or bill(s) is (are) true and correct and that
the materials or services itemized thereon
for which charge is made were ordered and
received except
10-11- 2015
Signatr
Executive Director
Cost distribution ledger classification if Title
Carmel Redevelopment Commission
claim paid motor vehicle highway fund