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HomeMy WebLinkAbout180963 12/30/2009 7 CITY OF CARMEL, INDIANA VENDOR: 356934 Page 1 of 1 ONE CIVIC SQUARE SIGNATURE CONSTRUCTION LLC CHECK AMOUNT: $25,352.30 t a CARMEL, INDIANA 46032 720 3RD Ave SW CARMEL IN 46032 CHECK NUMBER: 180963 CHECK DATE: 12/30/2009 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 902 4460873 5,596.89 PARCEL 5 STREETS CAPE 902 4460874 13,005.00 IDC PARKING GARAGE 902 4460893 4,777.00 IND DESIGN STREETSCAP 902 4460894 1,973.41 RANGE LINE ROAD -SOUTH APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE ONE OF 2 PAGES TO OWNER: CRC at City of Cannel PROJECT: Parcel 94 Strectscape APPLICATION NO: Invoice 113 1 Distribution to: Invoice if 3 Signature costs 'OWNER Carmel Indiana 46032 'ARCHITECT PERIOD TO: 11/24/2009 1 X 'CONTRACTOR FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design 1 1 Signature Construction Services LTC 720 3rd Avenue S.W. PROJECT NOS: Carmel, Indiana 46032 CONTRACT FOR: CONTRACT DATE: CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractors kitowiedge, Application is made for payment, as shown below, in connection with the Contract. information and belief the Work covered by this Application for Payment has been Continuation Sheet, AIA Document (3703, is attached. completed in accordance with the Contract Documents, that all amounts have been paid by the Contractor for Work tor 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 S 14,005.27 2. Net change by Change Orders 0.00 CONTRACTOR: 3. CONTRACT SUM TO DATE (Line 1 2) S 14,005,27 4. TOTAL COMPLETED STORED TO S 13,880.02 By: Date: t/ 1.zy 1 or 5. REfAINAGE: omas ontz, 'rest. ent �L a. 0 of Completed Work 5 0 Sub- ribed and om to before me this c p 1 ay of November, 2009 (Column D E on 6703) b. of stored Material S 1�+.'Aye-.,, LINDA BUCHANAN (l'olumn F on 3703) 0i Hancock County Iota] Retamage (Lines D9+ Dn or My Commission Expires Total in Column lofG703) s 0.00 AKCFII I tCI'S CEKIIFICAI t I }'AYMI_N I ',`?F, "r August 20, 2011 6. TOTAL EARNED LESS RETAINAGE 0 13,880,02 In accordance with the Contract Documents, based on on -site observations and the data (Line 4 Less Line 5 Total) comprising the application, the Architect certifies to the Owner that to the best of the 7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge, information and belief the Work has progressed as indicated, PAYMENT (Line 6 from prior Certificate) 0 11,906.61 the quality of the Work is in accordance with the Contract Documents, and the Contractor 8. CURRENT PAYMENT DUE 5 1,973.41 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE To FINISH, INCLUDING RETAINAGE S 125.25 (Line 3 less Line 6) AMOUNT CERTIFIED 1 44 LHANEE URDER SUMMARY AUU11IONS UEDUC HUNS (Attach erplana it iJ amount certified differs front the amount applied. Initial all figures on this Iotal changes approved Application d ont. e Continu 1011 sheet that are changed to canform with the amount certified.) l� .6....._ Total approved this Month By: /�7 in previous months by Owner ARCH 1T "I': �j� Y Date: ifr zs I D TOTALS 50.00 00.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the ...OmI ECM uameu inn cm. issndnCC, payment alit accepLmtee 01 payntem inc WIntUlil NET CHANGES by Change Order S0.00 prejudice to any rights of the Owner or Contractor under this Contract. AIA DOCUMENT G702 APPLICATION AND CERTIFICATION FOR PAYMENT 1992 EDITION AIA ©1992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE.. N.W.. WASHINGTON DC 20606 -5292 Users may obtain validation of this document by requesting a completed AIA Document D401 Certification of Document's Authenticity from the Licensee. SIGNATURE CONSTRUCTION LLC 720 3rd Avenue, S. W. Carmel, Indiana 46032 1 Invoice 3 11/24/09 Parcel 94 Streetscape Carmel, Indiana 1 WORK 1 BALANCE COMPLETED RETAINAGE PREVIOUS TOTAL COMPLETED TO ORIGINAL BUDGET Current DESCRIPTION THIS PERIOD WITHHELD APPLICATIONS TO DATE 1 FINISH BUDGET ADJUSTMENTS Budget General Requirement: Project Management 0.00 1,318.50 1,318.50 100% 0.00 1,318.50 1,318.50 Site Management 1,073.41 0.00 6,250.11 7,323.52 100% 0.00 0.00 7,323.52 7,323.52 Design Drawings 0.00 483.25 483.25 100% 0.00 0.00 483.25 483.25 Construction Management Fee 900.00 0.00 3,854.75 4,754.75 97% 125.25 0.00 4,880.00 4,880.00 1,973.41 0.00 11,906.61 13,880.02 0% 125.25 0.00 14,005.27 14,005.27 CONDITIONAL AFFIDAVIT AND WAIVER OF LIEN STATE OF INDIANA COUNTY OF HAMILTON Thomas E. Koontz being duly sworn states that he is the President of Signature Construction, LLC having contract to furnish certain materials and or labor as follows: Construction Management Services for a project known as Parcel 94 Streetscape, located at Carmel, Indiana and owned by the Carmel Redevelopment Commission and does state: CONDITIONAL WAIVER: that the balance due from the owner is the sum of one thousand nine hundred seventy -three dollars and forty -one cents ($1,973.41) the payment of which has has been promised as the sole consideration for this Affidavit and Conditional Waiver of Lien which is given to and for said amount, effective upon receipt of such cash payment. THEREFORE, the undersigned waives and releases unto the Owner of said premises any and all line or claim whatsoever on the above described property and improvements thereon on account of labor or material or both, finished by the undersigned thereto, and further certifies that no other party has any claim or right to a lien on account of any work perform or material furnished to the undersigned for the said project, and within the scope of this affidavit and waiver. SIGNATURE CONSTRUCTION, LLC 1 1 omas 'otin 'r• :ident Subscribed and sworn to before me this: j/ /fit( In q Notary Public: ,r LI NDA BUCHANAN :r. Hancock County My Commission Expires August2o,2011 APPLICATION AND CERTIFICATION FOR PAYMENT AM DOCUMENTG702 PAGE ONE OF 2 PAGES2 TO OWNER Carmel Redevelopment Commission PROJECT: Parcel 74 APPLICATION NO 12 Distribution to: One Civic Square Indiana Design Center 1 (OWNER, Carmel, Indiana 46032 Parking Garage PI2 1 IA.RCHITECT PERIOD TO: 11/24/09 1 X (CONTRACTOR FROM CONTRACTOR: VIA ENGINEER: CSO Schenkel Schultz I. I Signature Construction LLC 600 E. 96th Street I I 720 3rd Avenue S.W. Indpls., In. 46240 PROJECT NOS: 23233HC Carmel, Indiana 46032 CONTRACT DATE 01/12/07 CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, Application is made for payment, as shown below, in connection with the Contract. information and belief the Work covered by this Application for Payment has been Continuation Sheet, AEA Document G703, is attached. 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 issued and payments received from the Owner, and that current payment shown herein is now due. 1. ORIGINAL CONTRACT SUM 1,205,000.00 2. Net change by Change Orders 35,330.85 CONTRACTOR: 3. CONTRACT SUM TO DATE (Line 1 2) 1,240,330.85 4. TOTAL COMPLETED STORED TO 1,240,330.85 By: Date: /L4 5. RETAINAGE: homas.. roontz,President a. 0.05 of Completed Work 0.00 Su•scribed an' sworn to before me this id-- of god 4 (Column D E on G703) b. of Stored Material LINDA BUCHANAN Ha ncock Count (Column F on G703) My Commission Expires Total Retainage (Lines 5a 5b or .enOnct 90, 2011 Total in Column I ofG703) 0.00 ENGINEER'S CERTIFICATE FOR PAYMENF g9...• 6. TOTAL EARNED LESS RETAINAGE 1,240,330.85 In accordance with the Contract Documents, based on on -site observations and the data (Line 4 Less Line 5 Total) comprising the application, the Engineer certifies to the Owner that to the best of the 7. LESS PREVIOUS CERTIFICATES FOR Engineer's knowledge, information and belief the Work has progressed as indicated, PAYMENT (Line 6 from prior Certificate) 1,227,325.85 the quality of the Work is in accordance with the Contract Documents, and the Contractor 8. CURRENT PAYMENT DUE 13,005.00 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH, INCLUDING RETAINAGE 0.00 (Line 3 less Line 6) AMOUNT CERTIFIED 8 13 1 005 _0 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanatio a fount certified differs from the amount applied. Initial all figures on this Total changes approved Application an tithe ontinuation Sheet that are changed to conform with the amount certified.) in previous months by Owner ENGINEER: r� G Total approved this Month By: 0. `e/'�� Date: iloy V 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 Ot payment are without NET CHANGES by Change Order $0.00 prejudice to any rights of the Owner or Contractor under this Contract. AIA DOCUMENT G702 APPLICATION AND CERTIFICATION FOR PAYMENT 1992 EDITION AIA 01992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE.. N.W., WASHINGTON, DC 20006 -5292 Users may obtain validation of this document by requesting a completed AIA Document D401 Certification of Document's Authenticity from the Licensee. G703 CONTINUATION SHEET Page 1 of 1 To: From: Project: Application No.: 12 Carmel Redevelopment Commission Signature Construction LLC Parcel 74 Application Date: 11/24/09 One Civic Square 720 3rd Avenue S.W. Indiana Design Center Period To: 11/24/09 Carmel, Indiana 46032 Carmel, Indiana 46032 Parking Garage P12 Engineer's Project No. 23233HC A B C D I E F G H I Work Completed Materials Total Presently Completed Balance Retainage Item Scheduled From Previous Stored and Stored To If Description of Work Value Application This Period (Not in To Date (G /C) Finish Variable D or E) (D +E +F) (C -G) 101 General Requirement 277,700.00 277,700.00 0.00 0.00 277,700.00 100% 0.00 0.00 102 Existing Conditions 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 103 Concrete 455,287.50 455,287.50 0.00 0.00 455,287.50 100% 0.00 0.00 104 Masonry 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 105 Metals 140,000.00 140,000.00 0.00 0.00 140,000.00 100% 0.00 0.00 106 Wood, Plastics and Composites 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 107 Thermal and Moisture Protection 22,400.00 22,400.00 0.00 0.00 22, 400.00 100% 0.00 0.00 108 Openings 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 109 Finishes 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 110 Specialties 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 111 Equipment 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 112 Furnishings 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 113 Special Construction 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 114 Conveying Equipment 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 121 Fire Suppression 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 122 Plumbing 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 123 Heating, Ventilation AC 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 125 Integrated Automation 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 126 Electrical 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 127 Communications 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 128 Electronic Safety Security 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 131 Earthwork 331,938.35 331,938.35 0.00 0.00 331, 938.35 100% 0.00 0.00 132 Exterior Improvements 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 133 Utilities 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 134 Transportation 0.00 0,00 0.00 0.00 0.00 0% 0.00 0.00 140 Process Integration 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 141 Material Processing Handling Equip. 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 Rolling Garage Doors 13,005.00 0.00 13, 005.00 0.00 13, 005.00 100% 0.00 0.00 0% 0.00 1,240,330.85 1,227,325.85 0.00 0.00 1,240,330.85 100% 0.00 0.00 PARTIAL Payment to Follow AFFIDAVIT AND WAIVER OF LIEN STATE OF INDIANA SS: COUNTY OF HAMILTON Thomas E. Koontz being duly sworn states that he is the President of SIGNATURE CONSTRUCTION, LLC having contracted to furnish certain materials and /or labor as follows: Site Development for a project known as PARCEL 74, INDIANA DESIGN CENTER PARKING GARAGE P12, located at CARMEL, IN and owned by Carmel Redevelopment Commission and does further state: PARTIAL WAIVER: that the balance due from the owner is the sum of thirteen thousand five dollars and no cents (13,005.00) the payment of which has been promised as the sole consideration for this Affidavit and. Partial Waiver of Lien which is given to and for said amount, effective upon receipt of such payment. THEREFORE, the undersigned waives and releases unto the Owner of said premises any and all lien or claim whatsoever on the above described property and improvements thereon on account of labor or material or both, furnished by the undersigned thereto, and further certifies that no other party has a any claim or right to a lien on account of any work performed or material furnished to the undersigned for said project, and within the scope of this affidavit and waiver. SIGNATURE CONSTRUCTION, LLC pomas E. Koontz President Subscribed and sworn to before me this: 1 aV a l' Notary Public: _20` Y'P LINDABUCHANAN Nor av Hancock County SEAL My Commission Expires ''to Fjri4`'•' August 20, 2011 1 APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENTG702 PAGE ONE OF 2 PAGES2 TO OWNER CRC at City of Cannel PROJECT: Carmel City Parcel 73 APPLICATION NO: Invoice 3 I Distribution to: One Civic Square Signature costs 1 OWNER Carmel Indiana 46032 1 'ARCHITECT PERIOD TO: 11/24/2009 1 X CONTRACTOR FROM CONTRACTOR VIA ARCHITECT: Pedcor Design 1 Signature Construction Services LLC 720 3rd Avenue S W_ PROJECT NOS: Carmel. Indiana 46032 CONTRACT FOR: CONTRACT DATE: CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, Application is made for payment, as shown below. in connection with the Contract. information and belief the Work covered by this Application for Payment has been Coutinoalon Sheet AIA Document G703. is attached. 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 issued and payments received from the Owner, and that current payment shown herein is now due. L ORIGINAI. CONTRACT SLIM 5 20,858.00 2. Net chance by Charge Orders 5 0.00 CONTRACTOR: 3. CONTRACT SUM TO IJATI3 (1_mc I i( 2) 5 20,858.00 4 TOTAL COMPLETED STORED TO 5 19,337.12 T By: Date: Z 5 RETAINAGE: omas r' oontz, 'rest.ent a. 0 of Completed Work 5 0 •ubscribed an. .worn to before me this S day or November. 2009. (Column 0 Eon (3703) ,aidy LINDA BUCHANAN h. %ot'Stored 01ata t:d S •.I (olumn F on G iO3) N oaa Y Hancock County total ttentmage 11.0905 as t 3n or SEa Commission Expires Total in Column I of G703) 5 0.00 August Zan, 2011 'r 6 TOTAI. EARNED' F55 RIrFAINAGE 5 19,337.12 la accordance with the Contract Documents, based on on -site observations and the data (Line 4 Less line 5 Total) comprising the application, the Architect certifies to the Owner that to the best of the 7. LESS PREVIOUS CERTIFICATES POR Architect's knowledge, information and belief the Work has progressed as indicated, PAYMENT (Line 6 lions prior Certificate) 5 13,740.23 the quality of the Work is in accordance with the Contract Documents, and the Contractor S. CURRENT PAYMENT DUE 5 5,596.09 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO 0)01511, INCLUDING RETAINAGE 5 1,520.89 (Line 3 less Line 6) AMOUNT CERTIFIED 5 5 r C HANOI, ORDER SUnMAR S4 AUDI HUNS UEUUC I IONS (Attach explanation if fount certified differs from the amount applied. Initial all Jih'n res on r1ris I D I oral changes approved Application and o .ontinuation Sheet that are changed to conform with the amount cerl Jied) m previous months by Owner ARCHITECT: Total approved this Month By: Date. 1/15010, TOTALS 50.00 50.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Lunuactor naneu nerem- Issuance, payment utu acceptance Ut paymem 410 wall/Alt NET CHANGES by Chance Order 50.00 prejudice to any rights of the Owner or Contractor under this Contract, AIA DOCUMENT G792 APPLICATION AND CERTIFICATION FOR PAYMENT 1992 EDITION AIA -01992 THE AMERICAN INSTITUTE OF ARCHITECTS. 1735 NEW YORK AYE., NW WASHINGTON, DC 20006.5292 Users may obtain validation of this document by requesting a completed AIA Document 0401 Certification of Document's Authenticity from the Licensee. SIGNATURE CONSTRUCTION LLC 720 3rd Avenue, S. W. Carmel, Indiana 46032 Invoice 3 11/24/09 Carmel City Parcel 73 Carmel, Indiana Total Work RETAINAGE BALANCE Scheduled Completed WITHHELD PREVIOUS TOTAL COMPLETED TO DESCRIPTION Value This period THIS PERIOD APPLICATIONS TO DATE FINISH General Requirement: Testing 352.75 0.00 0.00 352.75 352.75 100% 0.00 Project Management 4,975.80 0.00 0.00 4,975.80 4,975.80 100% 0.00 Site Supervision 5,329.81 322.82 0.00 5,006.99 5,329.81 100% 0.00 Site Safety Director 0.00 0.00 0.00 0.00 0.00 0% 0.00 Design Drawings 289.69 20.00 0.00 269.69 289.69 100% 0.00 Sanitary Facilities 0.00 0.00 0.00 0.00 0.00 0% 0.00 Final Clean 0.00 0.00 0.00 0.00 0.00 0% 0.00 Constructin Management Fee 9,909.95 5,254.07 0.00 3,135.00 8,389.07 85% 1,520.89 20,858.00 5,596.89 0.00 13,740.23 19,337.12 93% 1,520.89 L CONDITIONAL AFFIDAVIT AND WAIVER OF LIEN STATE OF INDIANA COUNTY OF HAMILTON Thomas E. Koontz being duly sworn states that he is the President of Signature Construction, LLC having contract to furnish certain materials and or labor as follows: Construction Management Services for a project known as Carmel City Parcel 73, located at Carmel, Indiana and owned by the Carmel Redevelopment Commission and does state: CONDITIONAL WAIVER: that the balance due from the owner is the sum of five thousand five hundred ninty -six dollars and eighty -nine cents ($5,596.89) the payment of which has been promised as the sole consideration for this Affidavit and Conditional Waiver of Lien which is given to and for said amount, effective upon receipt of such cash payment. THEREFORE, the undersigned waives and releases unto the Owner of said premises any and all line or claim whatsoever on the above described property and improvements thereon on account of labor or material or both, finished by the undersigned thereto, and further certifies that no other party has any claim or right to a lien on account of any work perform or material furnished to the undersigned for the said project, and within the scope of this affidavit and waiver. SIGNATURE CONSTRUCTION, LLC f omas 6. oontz, President Subscribed and sworn to before me this: 1 /a5 q Notary Public: LINDA BUCHANAN Hancock County My Commission Expires August 20, 2011 APPLICATION AND CERTIFICATION FOR PAYMENT All DOCUMENT G702 PAGE ONE OF 2 PAGES TO OWNER: CRC at City °I PROJECT: Parcel 93 Streetscape APPLICATION NO: invoice a 2 1 Distribution to: It voice 0 2 Signature costs r ,OWNER Cannel Indiana 46032 'ARCHITECT PERIOD TO 1 I/24/2009 L X 'CONTRACTOR FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design r 1 Signature Construction Services LLC 720 3rd Avenue S.W. PROJECT NOS: Carmel, Indiana 46032 CONTRACT FOR: CONTRACT DATE: CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge. Application is made tor payment, as shown below, in connection with the Contract. information and belief the Work covered by dos Application for Paytnent has been Contumation Sheet, \1.A Document H703. is attached. 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 Issued and payments received from the Owner, and that current payment shown herein is now due. I. ORIGINAL CONTRACT SUM 5 11,752.70 2. Net change. by Change Orders 5 0.00 CONTRACTOR: 3. CONTRACT SUM TO DATE (Line I 21 11,752. 4. TOTAL CO:MPLL 1 ED STORED TO 3 11352.70 1 By: Z Date: f 7 5. RETAINAGL: mas -.7 'resi.ent a. 0 %of Completed Work 5 0 Subs 'bed and sw. to before me this a I(_ d of July, 2009 (Co4umil D E on 6703) b. 5, oI Stored Matenal 3 .:19-.• r LINDA BUCHANAN a P Hancock County II funln Ton (.37(131 noT,av [mat xetamage (Lines 5a tt or >�'+r My Commission Expires Total in Column i of 67031 s 0 -0o AKGH11 t(.... 1 'S CtK 1 II 1 t P P AYNI N I r August 20 2011 6. 1 A EARNED LESS RE AINAGE 5 11,752.70 In accordance with the Contract Documents, based on on -site observations and the data (One 4 Less Lure 5 Total) comprising the application, the Architect certifies to the Owner that to the best of the 7- LESS PREVIOUS CERTIFICATES FOR Architect's knowledge, information and belief the Work has progressed as Indicated. PAYMENT (Line 6 tiom pnor Cendicate) 5 6,975.70 the quality of the Work is in accordance with the Contract Documents, and the Contractor 9. CURRENT PAY NtEN'f DUE 3 4,77700 is entitled to payment of the AMOUNT CERTIFIED. V 9. BALANCE TO FINISH. INCLUDING RETAINAGE 5 0.00 (Line 3 less One 6) AMOUNT CERTIFIED 5 41 177. 11 iloc 1 DIP 10 (Auach explanati Jf moan! cert j d differs from the amount applied. Initial all figures on this total changes approved Application a ant? Conlin Sheet that are changed to confarnt with the amount certified) In previous months by Owrier ARCHITEC" Total approved this Month By: i l i Date: 1//3 TOTALS 50.00 50.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the t..uilllac Wl lIallleu !lei C111, issuance, paynlelll aura acceptativc Ul paymelll ale wiiliuut NET CHANGES by Change Order 50.00 prejudice to any rights of the Owner or Contractor under this Contract. AIA DOCUMENT G102 APPLICATION AND CERTIFICATION FOR PAYMENT 1902 EDITION •.AIA 01992 tHE AMERICAN INSTITUTE OF ARCHITECTS. 1735 NEW YORK AVE., N.W.. WASHINGTON, DC 20006-5292 Users may obtain validation of this document by requesting a completed AIA Document D401 Certification of Document's Authenticity from the Licensee. SIGNATURE CONSTRUCTION LLC 720 3rd Avenue, S. W. I Carmel, Indiana 4 6 0 3 2 1 1 1 i Invoice 2 11/24/09 Parcel 93 Streetscape Carmel, Indiana i I I 1 WORK i BALANCE COMPLETED RETAINAGE PREVIOUS TOTAL COMPLETED TO ORIGINAL BUDGET Committed DESCRIPTION THIS PERIOD WITHHELD APPLICATIONS TO DATE FINISH BUDGET ADJUSTMENTS Cost General Requirement: Project Management 0.00 1,318.56 1,318.56 0% 0.00 1,318.56 1,318.56 Site Management 0.00 5,173.91 5,173.91 0% 0.00 0.00 5,173.91 5,173.91 Design Drawings 0.00 483.23 483.23 0% 0.00 0.00 483.23 483.23 Construction Management Fee 4,777.00 0.00 0.00 4,777.00 0% 0.00 0.00 4,777.00 4,777.00 4,777.00 0.00 6,975.70 11,752.70 0% 0.00 0.00 11,752.70 11,752.70 i 1 1 1 1 r CONDITIONAL AFFIDAVIT AND WAIVER OF LIEN STATE OF INDIANA COUNTY OF HAMILTON Thomas E. Koontz being duly sworn states that he is the President of Signature Construction, LLC having contract to furnish certain materials and or labor as follows: Construction Management Services for a project known as Parcel 93 Streetscape, located at Carmel, Indiana and owned by the Carmel Redevelopment Commission and does state: CONDITIONAL WAIVER: that the balance due from the owner is the sum of four thousand seven hundred sevety -seven dollars and zero cents ($4,777) the payment of which has been promised as the sole consideration for this Affidavit and Conditional Waiver of Lien which is given to and for said amount, effective upon receipt of such cash payment. THEREFORE, the undersigned waives and releases unto the Owner of said premises any and all line or claim whatsoever on the above described property and improvements thereon on account of labor or material or both, finished by the undersigned thereto, and further certifies that no other party has any claim or right to a lien on account of any work perform or material furnished to the undersigned for the said project, and within the scope of this affidavit and waiver. SIGNATURE CONSTRUCTION, LLC AS. f z om.. ..n resi.en Subscribed and sworn to before me this: 1��d-WO Notary Public: aY LINDA BUCHANAN Hancock County SE., My Commission Expires August 20, 2011 Prescribed by Stale 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 service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee S" P ,°7_, ��,SPA -zi LL C Purchase Order No. 7 2c) 0�.. S.GV Terms J C /42 l a Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) (b2y /a) 3 1 /9 73 ..x/ )//'//e 2 f 74 /V /a 9 3 7 ff 4 s SW. F) /O 2 3 �7�Yr� S�cr L17 7 -Uc) Total 2 S 3,:s 2. .30 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 Clerk- Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 6 0' 74 "r 4' or�si�v� an r�ru; l mss LAC- IN SUM OF 3ro'r., S.z.v /z z S 1 352 -30 ON ACCOUNT FOR 777 10 Board Members Po# or INVOICE NO. ACCT #/TITLE AMOUNT hereby certify invoice( s), DEPT- I hereb certif that the attached invoices or. 3 l7/ 2 Y 19 75''/ bill(s) is (are) true and correct and that the 9 2 2 ''7045 7 y /3. Uo.5 Cei materials or services itemized thereon for x/11 3 4' c'r 7.3 5, Spy. 9 which charge is made were ordered and 2 yy1�cr 3 `/,7 7c9 received except /2 A p Director O erations Cost distribution ledger classification if Title claim paid motor vehicle highway fund