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HomeMy WebLinkAbout181725 01/25/2010 °�c CITY OF CARMEL, INDIANA VENDOR: 356934 Page 1 of 1 ONE CIVIC SQUARE SIGNATURE CONSTRUCTION LLC CHECK AMOUNT: $4,931.70 g s:, CARMEL, INDIANA 46032 720 3RD AVE SW z CARMEL IN 46032 CHECK NUMBER: 181725 CHECK DATE: 1/25/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 902 4460805 111 -2 4,931.70 RETAIL SITE #5 APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENTG702 PAGE ONE OF 2 PAGES TO OWNER: CRC at City of Carmel PROJECT: Carmel City P11 1 Waterproofing APPLICATION NO: Invoice 4 2 1 Distribution to: Onc Civic Square Signature costs 1 (OWNER Carmel Indiana 46032 1 'ARCHITECT PERIOD TO: 12/16/2009 1 X (CONTRACTOR FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design 1 Signature Construction Services LLC 1 720 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 Continuation Sheet, AIA Document G703, is attached. completed in accordance with the Contract Documents, that all amounts have been paid by the Contractor for Work tor which previous Certificates tor Payment were issued and payments received from the Owner, and that current payment shown herein is now due. 1. ORIGINAL CONTRACT SUM 10,695.78 2. Net change by Change Orders 0.00 CONTRACTOR: 3. CONTRACT SUM 'TO DATE (Line 1 2) 5 10,695. /8 4. TOTAL COMPLETED STORED TO 10,695. /8 //7/ By Date: z 5. RETAINAGE. oma fpontz, •resl.cnt a. 0 of Completed Work 0 Sub•cribed and s /orn to before me this /7 day of December, 2009 (Column D +EonG703) b. of Stored Material `I LINDA BUCHANAN (Column F on 6703) l .a3TA9 Hancock County r My Commission Expires t otal tte[amage (Lines �a .ti et .11 Total in Column I of G703) 0.00 i of. r 6. TOTAL EARNED LESS RETAINAGE 10,695.78 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) 5,764.08 the quality of the Work is in accordance with the Contract Documents, and the Contractor 8. CURRENT PAYMENT DUE 4,931.10 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH, INCLUDING RETAINAGE 0.00 (Line 3 less Line 6) AMOUNT CERTIFIED 4-P)5( 7I 141 1 •11 1 '1 1 D V 1 (Attach expla tion if mount certified diJers from the amount applied. Initial ail figures on this total changes approved Application and ont Conti ion Sheet that are changed to conform with the amount certified.) in previous months by Owner ARCI-IIT1dCT: Total approved this Month By: (JCL— Date: 12.172/09 TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Lt1111.fdekOf nameu nerelu. tssuanee, puymeni Will actxprauce 01 payment are WILHOUI NET CHANGES by Change Order $0.00 prejudice to any rights of the Owner or Contractor under this Contract. AIA DOCUMENT G702 APPLICATION ANC. CERTIFICATION FOR PAYMENT 1992 EDITION AIA ©1992 THE AMERICAN INSTITUTE OF ARCH4TECTS, 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. CONDITIONAL AFFIDAVIT AND WAIVER OF LIEN '4 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 1 or labor as follows: Construction Management Services for a project known as Carmel City Center P111, 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 nine hundred thirty -one dollars and seventy cents ($4,931.70) the payrnent 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 low o as ontz, rest ent Subscribed and sworn to before me this: /7 7- O I' Notary Public e.,a4 4 1,aY P6 LINDA BUCHANAN NOTARY Hancock County 1 REAL 4 1 My Commission Expires "'i Au 20, 2011 SIGNATURE CONSTRUCTION LLC Aliblii,- 720 3rd Avenue, S. W. Carmel, Indiana 46032 I Invoice 2 12/16/09 Carmel City P111 Waterproofing Carmel, Indiana 1 1 1 1 Total Work RETAINAGE 1 BALANCE Scheduled Completed WITHHELD PREVIOUS TOTAL COMPLETED TO DESCRIPTION Value This period THIS FERIOD APPLICATIONS TO DATE I FINISH Pre Construction Services: Project Management 3,117.15 963.79 0.00 2,153.36 3,117.15 100% 0.00 Site Supervision 4,173.64 562.92 0.00 3,610.72 4,173.64 100% 0.00 General Conditions: 0.00 0.00 0.00 0.00 0.00 0% 0.00 Testing and Inspecting 0.00 0.00 0.00 0.00 0.00 0% 0.00 Project Management 0.00 0.00 0.00 0.00 0.00 0% 0.00 Site Supervision 373.50 373.50 0.00 0.00 373.50 0% 0.00 Site Safety Director 0.00 0.00 0.00 0.00 0.00 0% 0.00 Design Drawings 3,031.49 3,031.49 0.00 0.00 3,031.49 0% 0.00 Sanitary Facilities 0.00 0.00 0.00 0.00 0.00 0% 0.00 Field Office 0.00 0.00 0.00 0.00 0.00 0% 0.00 Temporary Electric 0.00 0.00 0.00 0.00 0.00 0% 0.00 Office Supplies 0.00 0.00 0.00 0.00 0.00 0% 0.00 Temporary Telecommunications 0.00 0.00 0.00 0.00 0.00 0% 0.00 Temporary Water 0.00 0.00 0.00 0.00 0.00 0% 0.00 Tools and Equipment 0.00 0.00 0.00 0.00 0.00 0% 0.00 Project Signage 0.00 0.00 0.00 0.00 0.00 0% 0.00 Field Engineering and Surveying 0.00 0.00 0.00 0.00 0.00 0% 0.00 Health and Safety 0.00 0.00 0.00 0.00 0.00 0% 0.00 Waste Disposal 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 Construction Management Fee 0.00 0.00 0.00 0.00 0.00 0% 0.00 10,695.78 4,931.70 0.00 5,764.08 10,695.78 100% 0.00 1 1 1 1 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 service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee 5'1 9 n& utrc (o0f N (I b Purchase Order No. 720 Sri Ave 5. W Terms C IV, 1 I At `i 639- Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) —1 O 4 111 Wikf e r p roof i h a i .70 Total J 9 3) 70 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 5'19 ha -kkre Coh ruCti011 IN SUM OF 720 3rd Av. 5, V, C mc\ 1 I N 0,2 ON ACCO NT OF APPROP' IATION FOR r Board Members DEP T. or INVOICE NO. ACCT #!TITLE AMOUNT I hereby certify that the attached invoice(s), or QgQ j 4,11).7io bills) is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except 6-200 Si pture Direct• of Operatic Title Cost distribution ledger classification if claim paid motor vehicle highway fund