182727 03/02/2010 CITY OF CARMEL, INDIANA VENDOR: 356934 Page 1 of 1
ONE CIVIC SQUARE SIGNATURE CONSTRUCTION LLC
CARMEL, INDIANA 46032 720 3RD AVE SW CHECK AMOUNT: $4,278.08
CARMEL IN 46032 CHECK NUMBER: 182727
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CHECK DATE: 3/2/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
902 4460873 1 4,278.08 PARCEL 5 STREETSCAPE
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APPLICATION AND CERTIFICATION FOR PAYME AIA DOCUMENT G702 PAGE ONE OF 2 PAGES2
TO OWNER CRC at City of Cartel PROJECT: Carmel Parcel 73 APPLICATION NO Invoice H I 1 Distribution to:
One Civic Square Streetscape Signature costs =OWNER
Carmel Indiana 46032 =ARCHITECT
PERIOD TO: 01/26/10 CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design
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
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 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 4,278.08
2. Net change by Change Orders 0.00 CONTRACTOR:
3, CONTRACT SUM TO DATE (Line 1 2) 4,278.08
4. TOTAL COMPLETED STORED TO 4,
By: Date: 6 /Q
5. RETAINAGE: 171omas E. ontz, President
a. 0 of Completed Work 0 Sub Bribed and s orn to before me this of
(Column D F on G703)
LINDA BUCHANAN
b. of Stored Material
Hancock County
{Column F on G703} Nor.PY
Total Retainage (Lines 5a 5b or s s sE.J� My Commission 0 Ej pins
Total in Column I of G703) 0.00 A CERTIFICATE A E
6. TOTAL EARNED LESS RETAINAGE 4,278.08 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 Ovvner 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) 0.00 the quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE 4,278.08 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE 0.00
(Line 3 less Line 6) AMOUNT CERTIFIED 7b,0&
CHANGE ORDER SUMMARY ADDITIONS D (Attach explanati rf a punt certified d fifers from the amount applied. Initial all figures on this
Total changes approved Application a onthe ominuatio eet that are changed to conform with the amount certified.)
in previous months by Ow ner ARCHITEC
Total approved this Month By: Date:
TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
Uontractor namea nerem. Issuance, payment anct acceptance of payment are wmtout
NET CHANGES by Change Order 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 YORKAVE., N-W, WASHINGTON, DC 20000 -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
Invoice 1
1/26/10
Carmel City Parcel 73 Streetscape
Carmel, Indiana
WORK COMPLETED MATERIALS TOTAL BALANCE
ITEM DESCRIPTION OF SCHEDULED FROM PREVIOUS THIS PRESENTLY COMPLETED AND TO Committed
NO. WORK VALUE APPLICATIONS PERIOD STORED STORED TO DATE FINISH Cost
Pre Construction Services 4,278.08 0.00 4,278.08 0.00 4,278.08 100% 0.00 4,278.08
General Requirements: 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Testing and Inspecting 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Site Supervision 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Construction Management 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Site Safety Director 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Design Drawings 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Sanitary Facilities 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Field Office 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Temporary Electric 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Office Supplies 0.00 0.00 0.00 0.00 0,00 0% 0.00 0.00
Temporary Telecommunications 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Temporary Water 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Tools and Equipment 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Jobsite Trailer 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Field Enc. and Surveying 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Health and Safety 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Waste Disposal 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Final Clean 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Construction Management Fee 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
4,278.08 0.00 4,278.08 0.00 4,278.08 100% 0.00 4,278.08
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 73 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
two hundred seventy -eight dollars and eight cents ($4,278.08) 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, furnished 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
Th mas oontz, President
Sub cribed and sworn to before me this: 2 J an D acv
Notary Public:
„p PG LINDA BUCHANAN
'NO.AA Hancock County
a. 5 My Commission Expires
August 20, 2011
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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
'fvg J r��� �s LZ_ Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number note attached invoice(s) or bill(s)) �l�J
Total
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
IN SUM OF
ON ACCOUNT OF APRR90 PRIATION FOR
Board Members
Po# or INVOICE NO. ACCT /TITL-E AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
god Y�o�73 1 {27 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
2 20 ,-o
gnature
Dilrecttor of gedewiopm"
Tit (e
Cost distribution ledger classification if
claim paid motor vehicle highway fund