319154 11/30/2017 ' coq
CITY OF CARMEL, INDIANA VENDOR: 371394
i'. ONE CIVIC SQUARE MIDWEST ACCESSIBILITY CHECK AMOUNT: $****26,664.00*
CARMEL, INDIANA 46032 2050 STAPLETON COURT CHECK NUMBER: 319154
CINCINNATI OH 45240 CHECK DATE: 11/30/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 R4350100 24938 14,226.89 GARAVENTA CPL
1120 R4350100 24938 12,437.11 GARAVENTA CPL
VOUCHER NO. WARRANT NO. Prescribed by state Board of Accounts City Form No.201 (Rev.1995)
Vendor# 371394 ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
MIDWEST ACCESSIBILITY IN SUM of$ CITY OF CARMEL
2050 STAPLETON COURT 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.
CINCINNATI, OH 45240
Payee
$26,664.00
Purchase Order#
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire 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
24938 0 43-501.00 $12,437.11 1 hereby certify that the attached invoice(s),or 11/28/17 0 $12,437.11
1120 Encumbered 101 1120 101
24938 43-501.00 $14,226.89 bill(s)is(are)true and correct and that the 11/28/17 $14,226.89
1120 Encumbered 102 materials or services itemized thereon for 1120 1 102
which charge is made were ordered and
received except
Tuesday, November 28,2017
David Haboush
Fire Chief
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
APPLICATION AND CERTIFICATE FOR PAYMENT Page 1
To(OWNER): Carmel Fire Station Project: Carmel Fire Station Application No: 2
2 Civic Square 2 Civic Station Invoice No: 5582
Carmel, IN 46032 Carmel,IN 46032 Period To: 11/2/2017
From: Midwest Accessibility Products Via(Architect):
2050 Stapleton Ct Architect's
Cincinnati,OH 45240 Project No:
Contract Date:
CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for payment,as shown below,in connection with the
Contract.
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS 1. ORIGINAL CONTRACT SUM $ 26,664.00
2. Net change by Change Orders $ 0.00
Approved previous months 0.00 0.00 3. CONTRACT SUM TO DATE(LINE 1+/-2) $ 26,664.00
4. TOTAL COMPLETED&STORED TO DATE $ 26,664.00
Approved this month 0.00 0.00 (Column G on G703)
5. RETAINAGE $ 0.00
TOTALS 0.00 0.00 6. TOTAL EARNED LESS RETAINAGE $ 26,664.00
(Line 4 less Line 5)
Net change by change orders 0.00 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT $ 23,997.60
(Line 6 from prior Certificate)
8. SALES TAX $ 0.00
9. CURRENT PAYMENT DUE $ 2,666.40
10. BALANCE TO FINISH,PLUS RETAINAGE $ 0.00
(Line3 less Line 6)
The undersigned Contractor certifies that to the best of the Contractor's knowledge, State of- 66-0 County of: i
information and belief the Work covered by this Application for Payment has been Subscribed and sworn to before me this day of NOVtAti61i 7.011
completed in accordance with the Contract Documents,that all amounts have been
paid by the Contractor for Work for which previous Certificates for Payment were Notary Public.
issued and payment received from the Owner,and that current payment shown My Commission pires: 't..• ""'••.B1
herein is now due. JENNY L.CHAPMAN
By:
ONCTOR:)lgidwei Accessibility ProductsDate; Notary Public,State of Ohio
y — e rte' My Commission Expires
Mafeh 20
ARCHITECT'S CERTIFICATE FOR PAYMENT AMOUNT CERTIFIED.......... r3' '
..• @�Yhe(Attach explanation if amount ce 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 ARCHITECT:
Owner that to the best of the Architect's knowledge,information and belief the
work has progressed as indicated,the quality of the Work is in accordance with By Date
the Contract Documents,and the Contractor is entitled to payment of the This Certificate is not negotiable.The AMOUNT CERTIFIED ispayable only to the
AMOUNT CERTIFIED. Contractor named herein.Issuance,payment andacceptance of payment are without
prejudice to any rights of the Owner or Contractor under this Contract.
CONTINUATION SHEET Page 2
Application Number. 2
Application Date: 11/2/2017
Period To: 11/2/2017
Architects Project No:
A B C D E F G H I
ITEM DESCRIPTION OF WORK SCHEDULED WORK BILLED WORK BILLED MATERIALS TOTAL % BALANCE TO RETAINAGE
NO. VALUE FROM PREV THIS PERIOD STORED THIS COMPLETED (G/ FINISH(C-G)
APPLICATION PERIOD AND STORED C)
(D+E+F) TO DATE
D+E+F
01 Garaventa CPL Vertical 26,664 26,664 0 0 26,664 100 0 0
Wheelchair Lift
26,664 26,664 01 01 26,664 1 100 1 01 0
APPLICATION AND CERTIFICATE FOR PAYMENT Page 1
To(OWNER): Carmel Fire Station Project: Carmel Fire Station Application No: 1
2 Civic Square 2 Civic Station Invoice No: 5577
Carmel, IN 46032 Carmel, IN 46032 Period To: 11/2/2017
From: Midwest Accessibility Products Via(Architect):
2050 Stapleton Ct Architect's
Cincinnati,OH 45240 Project No:
Contract Date:
CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for payment,as shown below, in connection with the
Contract.
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS 1. ORIGINAL CONTRACT SUM $ 26,664.00
2. Net change by Change Orders $ 0.00
Approved previous months 0.00 0.00 3. CONTRACT SUM TO DATE(LINE 1+/-2) $ 26,664.00
4. TOTAL COMPLETED&STORED TO DATE $ 26,664.00
Approved this month 0:00 0.00 (Column G on G703)
5. RETAINAGE $ 2,666.40
TOTALS 0.00 0.00 6. TOTAL EARNED LESS RETAINAGE $ 23,997.60
(Line 4 less Line 5)
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT $ 0.00
Net change by change orders 0.00 (Line 6 from prior Certificate)
8. SALES TAX $ 0.00
9. CURRENT PAYMENT DUE $ 23,997.60
10. BALANCE TO FINISH, PLUS RETAINAGE $ 2,666.40
(Line 3 less Line 6) , I -__
The undersigned Contractor certifies that to the best of the Contractor's knowledge, State of: oh t o County of: t7gi► '< < ter,./=(-7
information and belief the Work covered by this Application for Payment has been Subscribed and swom to before me this Z- day of
completed in accordance with the Contract Documents,that all amounts have been C'��"Y ' ' �
paid by the Contractor for Work for which previous Certificates for Payment were Notary Public: -'_4
issued and payment received from the Owner,and that current payment shown My Commission pireso
herein is now due.
�P�Y PVB
CONRA£TOR: idwest A cessibility Products
By: Date: JENNY L.CHAPMAN
ARCHITECT'S CERTIFICATE FOR PAYMENT AMOUNT CERTIFIED........................... ... " o..., o ary Pulic,State of Ohio
(Attach explanation if amount certified differs orrr ,e or.�Y Commission Expires
In accordance with the Contract Documents, based on on-site observations March 30,2021
and the data comprising the above application,the Architect certifies to the ARCHITECT: '9TH OF O�
Owner that to the best of the Architect's knowledge, information and belief the
work has progressed as indicated,the quality of the Work is in accordance with .By Date
the Contract Documents,and the Contractor is entitled to payment of the This Certificate is not negotiable.The AMOUNT CERTIFIED is payable only to the
AMOUNT CERTIFIED. Contractor named herein. Issuance,payment and acceptance of payment are without
prejudice to any rights of the Owner or Contractor under this Contract.
CONTINUATION SHEET Page 2
Application Number: 1
Application Date: 11/2/2017
Period To: 11/2/2017
Architect's Project No:
A B C D E F G H I
ITEM DESCRIPTION OF WORK SCHEDULED WORK BILLED WORK BILLED 'MATERIALS TOTAL % BALANCE TO RETAINAGE
NO. VALUE FROM PREV THIS PERIOD STORED THIS COMPLETED (G/ FINISH(C-G)
APPLICATION PERIOD AND STORED C)
(D+E+F) TO DATE
D+E+F
01 Garaventa CPL Vertical 26,664 0 26,664 0 26,664 100 0 2,666
Wheelchair Lift
26,664 0 26,664 0 26,664 100 0 2,666