301409 07/28/16 i
"p''• CITY OF CARMEL, INDIANA VENDOR: 367957
.� ® •�• ONE CIVIC SQUARE LAYNE HEAVY CIVIL INC
CHECK AMOUNT: $****23,722.00*
CARMEL, INDIANA 46032 4520,N STATE ROAD 37 CHECK NUMBER: 301409
ORLEANS IN 47452 CHECK DATE: 07/28/16
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 1 23,722.00 OTHER EXPENSES
VOUCHER # 165791 WARRANT# ALLOWED
367957 IN SUM OF $
LAYNE INLINER LLC
4520 N STATE ROAD 37
ORLEANS, IN 47452
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
1 01-7360-02 23,722.00
Voucher Total 23,722.00
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
367957
LAYNE INLINER LLC Purchase Order No.
4520 N STATE ROAD 37 Terms
ORLEANS, IN 47452 Due Date 7/26/2016
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
7/26/2016 1 23,722.00
hereby certify that the attached invoice(s), or bill(s) is (are) true and
;orrect and I have audited same in accordance with IC 5-11-10-1.6
Date Officer
Contractor's Application For Payment No. 1 - FINAL
Application Period:May 1,2016-May 31,2016 Application Date: June 29,2016
To(Owner): City of Carmel,Indiana From(Contractor): Layne Inliner,LLC Via(Engineer):Jones&Henry Engineers,LTD
Project: Rolling Springs Culvert Sewer Lining Contract: Rolling Springs Culvert Sewer Lining
Owner's Contract No.: RFQ 1-16 Contractor's Project No.:41121 Contract P.O.Number:
Application for Payment
Change Order Summary
Approved Change Orders 1. ORIGINAL CONTRACT PRICE
$33,260.00
Number Additions Deductions 2. Net change by Change Orders $0.00
3. CURRENT CONTRACT PRICE(Line 1 t 2) $33,260.00
4. TOTAL COMPLETED AND STORED TO DATE $23,722.00
5. RETAINAGE:
a. _%x$_Work Completed $0.00
b. _%x$_Stored Material $0.00
c. Total Retainage(Line 5a+Line 5b) $0.00
6. AMOUNT ELIGIBLE TO DATE(Line 4-Line 5c) $23,722.00
TOTALS $ $ 7. LESS PREVIOUS PAYMENTS $0.00
8. AMOUNT UUP THIS APPLICATION $23,722A0
NET CHANGE BY CHANGE ORDERS $ 9. BALANCE TO FINISH,INCLUDING RETAINAGE $9,538.00
is recommended by:
Contractor's Certification (Engineer) (Date)
The undersigned Contractor certifies that: (1)all previous progress payments received from Owner is recommended by:
on account of Work done under the Contract have been applied on account to discharge (Date)
Contractor's legitimate obligations incurred in connection with Work covered by prior Applications for
Payment;(2)title of all Work,materials and equipment incorporated in said Work or otherwise listed payment of:$
in or covered by this Application for Payment will pass to Owner at time of payment free and clear of
all Liens,security interests and encumbrances(except such as are covered by a Bond acceptable to (Line 8 or other-attach explanation of other amount)
Owner indemnifying Owner against any such Liens,security interest or encumbrances);and(3)all
Work covered by this Application for Payment is in accordance with the Contract Documents and is is approved by:
not defective.
(Owner) (Date)
By: �(F--- Date: June 29,2016 Approved by:
Funding Agency(if applicable) (Date)
EJCDC No.C-620(2002 Edition)
Prepared by the Engineers'Joint Contract Documents Committee and endorsed by the Associated General Contractors of America and the Construction Specifications Institute.
Page 1
City of Carmel:Rolling Springs Culvert Sewer Lining Project
Change Order Extended
g Quantity Previous Quantity this Contract Quantity Contract Amount
Item No. Item Description Unit Unit Price Contract Quantity Quantities Periods Period Remaining Anticipated Amount Billed Comments
this Per(od
1 Mobilization/Demobilization LS $4,000.00 1.0 0.00 1.00. 0.00 $4,000.00 $4,000.00
2 15"Inliner CIPP LF $173.00 120.0 0.00 114.00 6.00 $20,760.00 $19,722.00
3 T-Liner Lateral Connection(as needed) EA $3,750.00 2.0 0.00 0.00 2.00 $7,500,00 $0.00 Not used
4 Root Cutting(as needed) LS $1,000.00 1.0 0.00 0.00 1.00 $1,000.00 $0.00 Not used
Amount Billed This Period: $13,722.00
Less Retainage(5.0%): $
Amo ntrOrretThu WIN-Awn}722T00