181561 01/20/2010 ,415 CITY OF CARMEL, INDIANA VENDOR: 00352393 Page 1 of 1
1. t ONE CIVIC SQUARE GRADEX, INC. CHECK AMOUNT: $147,138.21
CARMEL, INDIANA 46032 3685 PRIORITY WAY S. DRIVE
A o� 06 SUITE 140 CHECK NUMBER: 181561
INDIANAPOLIS IN 460240
CHECK DATE: 1(20/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
601 5023990 1 147,138.21 OTHER ACCT RECEIVABLE
APPLICATION AND CERTIFICATE FOR PAYMENT Invoice 9181 -1
To Owner: CITY OF CARMEL Project: 9181- CARMEL WATER TREATMENT Application No.: 1 Distribution to
CITY HALL PLANT 1 f Owner
1 CIVIC SQUARE 1 1 Architect
CARMEL, IN 46032 Period To: 11/30/2009 1 Contractor
1
From Contractor: Gradex, Inc. Via Architect: 1
3685 Priority Way S. Drive, Suite 140 Project Nos:
Indianapolis, IN 46240
Contract For: SITE PREP Contract Date: 11/1/2009
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge,
information, and belief, the work covered by this Application for Payment has been completed
Application is made for payment, as shown below, in connection with the Contract- in accordance with the Contract Documents. That all amounts have been paid by the Contractor
Continuation Sheet is attached.
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.
4. Original Contract Sum $962,248.00
2. Net Change By Change Order $0.00 CONTRACTOR: Gradex, Inc.
3. Contract Sum To Date $962,248.00
h
4. Total Completed and Stored To Date $163,486.90 By: Date: 12/08/09
5. Retainage
a 10.00% of Completed Work State of: India, a County of: Marion
$16,348.69 Subscribed and s before me day of December, 2009
h. 0.00% of Stored Material $0.00 Notary Public: ��r gill
My Commission expires: February 27th, 2016
Total Retainage $16,348.69
6. Total Earned Less Retainage $147,138.21 ARCHITECT'S CERTIFICATE FOR PAYMENT
In accordance with the Contract Doc based on on -site observations and the data
7. Less Previous Certificates For Payments comprising the above application, the Architect certifies to the Owner that to the best of the
$0.00 Architect's knowledge, information, and belief, the Work has progressed as indicated,
8. Current Payment Due $147,138.21 the quality of the Work is in accordance with the Contract Documents, and the Contractor
is entitled to payment of the AMOUNT CERTIFIED.
9. Balance To Finish, Plus Retainage $815,109.79
AMOUNT CERTIFIED 147,138.21
(Attach explanation if amount certified differs from the amount applied. Initial all figures on this Application and on the
Continuation Sheet that are changed to conform with the amount certified.)
CHANGE ORDER SUMMARY Additions Deductions
Total changes approved
in previous months by Owner $0 $0.00 ARCHIT
Total Approved this Month B Date: e7
$0.0 $0.00 Y
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 of payment are without
NetaChanges By Change Order $0.00 prejudice to any rights of the Owner or Contractor under this Contract.
er
Prescribed by State Board of Accounts
Form No. 301 (Rev. 1995) ACCOUNTS PAYABLE VOUCHER
TO
ADDRESS
Invoice Date Invoice Number Item Amount
hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and that the materials or services
itemized thereon for which charge is made were ordered and received except
Mo. Day Yr. Signature Title
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct a I have audited same in accordance
with IC 5- 11- 10 -1.6.
Mo. Day Yr. Offic Title
Voucher No. Warrant No.
ACCOUNTS PARABLE DETAILED ACCOUNTS
MUNICIPAL WATER DEPT. ACCT.
NO.
CARMEL, INDIANA
GRA y E Favor Of
36. 5 ILi o r: 1-1 (MA ct 5 P 2 1I
s1-e
Pip
1N� nNii pv l t 5 SO
Total Amount of Voucher
Deductions
11713
0 O.00
Amount of Warrant 1 r(113
t•
Month of Yr
Acct.
VOUCHER RECORD No.
Source of Supply
Water Treatment
Transmission and Dist.
Customer Accounts
Administrative and General II��
Operation Maintenance 11 1 0))
Utility Plant in Service
Constr. Work in Progress
Materials and Supplies
Customers Deposits
Total
Allowed 1.
Board of Control
Filed
Official Title
BOYCF FORMS SYSTEMS 7800 -382 -8702 325