318982 11/22/17 4y*. CITY OF CARMEL, INDIANA VENDOR: 365286
r1;
ONE CIVIC SQUARE HAGERMAN, INC CHECK AMOUNT: $***1 16,734.00*
CARMEL, INDIANA 46032 CHECK NUMBER: 318982
PO BOX 11848 CHECK DATE: 11/22/17
FORT WAYNE IN 46861
DEPARTMENT ACCOUNT PO NUMBER_ INVOICE NUMBER AMOUNT DESCRIPTION
902 4460805 100913 103561 116,734.00 VETERANS WAY EXT CONT
VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995)
Vendor# 365286 ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
— HAGERMAN, INC IN SUM OF$ CITY OF CARMEL
An invoice or bill to be properly itemized must show:kind of service,where performed,dates service
PO BOX 11848 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc.
FORT WAYNE, IN 46861
Payee
$116,734.00
ON ACCOUNT OF APPROPRIATION FOR Purchase Order#
Redevelopment Commission Terms
Date Due
PO# ACCT# DATE INVOICE# DESCRIPTION
DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT
100913 103561 44-608.05 $116,734.00 1 hereby certify that the attached invoice(s),or 10/18/17 103561 Veterans Way extension $116,734.00
902 902 902 902
bill(s)is(are)true and correct and that the
T materials or services itemized thereon for
which charge is made were ordered and
received except
Wednesday, November 22,2017
Mestetsky, Henry
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
,20
Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer
REQUEST FOR PAYMENT
From: Hagerman Inc To: SIGNATURE CONSTRUCTION
P O Box 11848-1848 Invoice: 103561
FortWayne, IN 46861 720 3rd Ave.S.W. Draw: APP#/00007RI
CARMEL,IN 46032 Invoice date: 10/18/2017
Contract For.Veteran's Way Period ending date: 10/31/2017
Request for payment:
Original contract amount $3,392,294.00
Approved changes $45,829.00 Proiect: 16-0815-1
Revised contract amount $3,438,123.00 Veteran's Wav
Contract completed to date $3,438,123.00 Contract date:
Add-ons to date $0.00
Taxes to date $0.00
Less retainage $0,00 Architect:
Total completed less retainage $3,438,123.00 Scope:
Less previous requests $3,094,310.63
Current request for payment $343,812.37
Current billing $0.00
Current additional charges $0.00
Current tax $0.00 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS
Less current retainage -$343,812.37 Changes approved in prenmous
Current amount due $343,812.37 months b Owner 45,829.00
Remaining contract to bill $0.00 Total approved this Month
TOTALS 45 829.00
NET CHANGES by Change Order 45,829.00
I hereby certify that the work performed and the materials supplied to date,as shown on the-above represent the actual value of the accomplistlment under the terms of the
Contract{and all authorized changes thereof)between the undersigned and the SIGNATURE CONSTRUCTION relating to the above referenced project I also certify that the
contractor has paid all amounts previously billed and paid by the owner
CONTRACTOR: Ha erman Inc State Of Indiana County Of Madison
By. Subscribed and sworn to before me this a2�day of X17
Date:_ I&hys 117 Notary Public Shane M Clarkson
My commission expires: 11-15-2W
Shane Michael Clarkson
72 ala,.37 C G. Notary Public,State of Indiana
Madison County
Commission#675501
My Commission Expires
I 3 `l 902 Nlovrember 15,2023
REQUEST FOR PAYMENT DETAIL
Project: 16-0815-11 Veteran's Way Invoice:103561 Draw:APP#OD007RI Period Ending Date. 10/31/2017 Detail Page 2 of 2 Pages
Item Description Total Previously Work Completed Balance to
°
ID Contract Completed Completed To Date �0 Finish Retainage
Amount Work This Comp Balance
Period
10D General Conditions 797,605.00 797,605.00 797,605.00 100.00 0.00
200 Earthwork 68,050.00 68,080.00 68,050.00 100.00 0.00
250 Auger Cast Piles 126,350.00 126,350.00 126,350.00 100.00 0.00
275 Landscaping 149,777.00 149,777.00 149,777.00 100.00 0.00
300 Concrete Materials and Labor 289,711.00 289,711.00 289,711.00 100.00 0.00
320 Reinforcing Steel 87,158.00 87,158.00 87,158.00 100.00 0.00
350 PreCast Concrete 687,000.00 687,000.00 687,000.00 100.00 0.00
400 Masonry 295,000.00 295,000.00 295,000.00 100.00 0.00
500 Omamental Metals 33,791.00 33,791.00 33;791.00 100.00 0.00
550 Thermal&Moisture 449,000.00 449,000.00 449,000.00 100.00 0.00
575 Metal Stud,DIFS,EIFS 101,200.00 101,200.00 101,200.00 100.00 0.00
600 Painting 25,235.00 25,235.00 25,235.00 100.00 0.00
625 Louvers&Vents 4,070.00 4,070.00 4,070.00 100.00 0.00
650 Mechanical/Plumbing 55,020.00 55,020.00 55,020.00 100.00 0.00
675 Fre Protection 23,640,00 23,640.00 23,640.00 100.00 0.00
700 Electrical 128,725.00 128,725.00 128,725.00 100.00 0.00
800 Allowance 2,444.00 2,444.00 2,444.00 100.00 0.00
901 C0#1 Storm Line(Allowance) 20,769.00 20,769.00 20,769,00 100.00 0.00
902 CO#02 ASI#01(Allowance) 2,380.00 2,380.00 2,380.00 100.00 0.00
903 OCO#04 PR#01 Expansion Joint 22,680.00 22,680.00 22,680,00 100.00 0.00
904 CO#03 Fur out wall(Allowance) 7,602.00 7,602.00 7,602.00 100.00 0.00
905 CO#05 PR#2 Concrete(Allowance 29,393.00 29,393.00 29,393.00 100.00 0.00
906 CO#06 Granite Changes(Allow) 1,026.00 11026.00 1,026.00 100.00 0.00
907 C0907 PR#3 Power(Allowance) 18,054.00 18,054.00 18,054.00 100.00 0.00
908 OCO#08 PR#Data 12,443.00 12,443.00 12,443.00 100.00 0.00
Totals 3,438.123.00 3,438,123.00 3,438,123.00 00.00 0.00
CONTRACTOR'S AND SUPPLIER'S AFFIDAVIT AND WAIVER OF LIEN
l Daraal Orman[to Follow
The undersigned,being first duly sworn on his oath or affirming,states that:
1 Greg Delagmage (Name) is the Project Manager (Title) of
Hagerman Inc (Corapany),(hereinafter called"Company') of and is familiar
with lite facts herein stated and makes this affidavit for and on behalf of himself and the Company,being duly
authorized to bind the Company by the statements herein contained.
2 The CompaM,,having contracted with Signirture Construction has performed work and labor
or furnished materials supplies'or equipment in the construction of certain improvements on the real estate commonly
known as Vei¢r"n's Way Eipnn,ion located at 8aegdiaa Rd&Dlaaan 81Q in, Carmel (City),
IN (State),which real estate is owned by Carmel Redevelopment Commission (hereinafter called"Owner").
3 Company has,or will within 10 days of receipt of payment due from Hagerman,Inc. noted in Item 4,paid for all work,
labor,materials,equipment,and suppliers perfortned or furnished by it and by its subcontractors,material-men and
suppliers upon such premises or in connection therewith and no person,other than Company,has any claim or right to a lien
for any work,materials or services on account of any transaction undertaken by company with respect to said premises,
except as specifically noted below; _
Name of Company Amount Owed Explanation for Withholding Payment
4 The amount due to Company from Signature Construction
PARTIAL WAVIER That the balance due is the sum of
receipt of which is hereby acknowledged.or
0 the payment of which is promised as the sole consideration for this Affidavit and Partial and Waiver of Lien which is given
to and for said amount,effective upon receipt of such payment.
FINAL WAIVER that the final balance due is the sum of
Three Hundred Forty-Three Thousand Eight Hundred Twelve Wars and 371100 ( $ 343,812.37 )
receipt of which is hereby acknowledged,or
Cl the payment of which is promised as the sole consideration of this affidavit and Final Waiver.of Lien which shallbecofne effective
upon receipt of such payment.
THEREFORE,the undersigned waivers and releases under the statutes of the state of Indiana.unto the Owner
of said premises,any and all lien of cWm whatsoever on the above-described property and improvements thereon account of LABOR
or material or both,furnished by the undersigned thereto,and farther certifies that no other party has any claim or right to a lien on account
of any work performed or material furnished to the undersigned for said project,except as noted above,and within the scope of this
afildevit and waiver.
Hagerman Inc
(Comps ,Nam
-_Title: Project Manager
(Sigrrafure of ericerl It=
Subscribed and sworn`- 18th day of October 20I7
County of Residence: Madison
tNo Public)
11/M023
(Aly Commission Expires)
Shane Michael Clarkson
Notary Public.Stale of Indiana
Madison County
Commission#675501
My Commission Expires
November 15,2023