183217 03/16/2010 CITY OF CARMEL, INDIANA VENDOR: 363756 Page 1 of 1
e p ONE CIVIC SQUARE BURNETTE FABRICATION INC
j� CARMEL, INDIANA 46032 415 PARK 800 DRIVE SUITE H CHECK AMOUNT: $8,995.00
GREENWOOD IN 46143 CHECK NUMBER: 183217
CHECK DATE: 3/16/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 R4463000 20028 14 8,995.00 RANGE HOOD
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Burnette Fabrication Invoice
415 Park 800 Drive Date Invoice
Suite 1 -1
Greenwood, IN 46143
2/9/2010 14
Bill To Ship To
A l7N Nam Lister
Brookshire Golf Carmel Indiana
12t20 Brookshire Pkwy 46033
1 20028
P.O. Number Terms Rep Ship Via F.O.B. Project
20028 Net 15 2/9/2010
Quantity Item Code Description Price Each Amount
Installation Exhaust hood new, installed with new A11sn1 fire system. 5,995.00 8,995.00
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Total 58,995.00
INDIANA RETAIL TAX EXEMPT PAGE
Cy f C rme l CERTIFICATE NO. 003120155 002 0
JJILL lVL l!i 1111 PURCHASE ORDER NUMBER
FEDERAL EXCISE TAX EXEMPT�
35- 60000972 i
ONE CIVIC SQUARE THIS NUMBER MUST APPEAR ON INVOICES, A/P
CARMEL, INDIANA 46032 -2584 VOUCHER, DELIVERY MEMO, PACKING SLIPS,
SHIPPING LABELS AND ANY CORRESPONDENCE.
FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL 1997
PURCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION
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tj() rn a ftlf l 61 (Ia.( c SHIP L -0
VENDOR qr llIC /�fl if TO baJ
CONFIRMATION BLANKET CONTRACT PAYMENT TERMS FREIGHT
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QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION
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Send Invoice To:
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PLEASE INVOICE IN DUPLICATE r;,, p(70
DEPARTMENT ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT
PAYMENT
A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O.
NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND
VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED.
SHIPPING INSTRUCTIONS I HEREBY CERTIFY THAT THERE IS AN UNOBLIGATED BALANCE IN
THIS AP PROPRIATION SUFFICIENT TO PAY FOR THE ABOVE ORDER.
SHIP REPAID.
C.O.D. SHIPMENTS CANNOT BE ACCEPTED. 1
PURCHASE ORDER NUMBER MUST APPEAR ON ALL ORDERED BY F�`Y"Ir` 1. ,1F- !f �1 f> 7" -lC/ J/
SHIPPING LABELS. f j�
THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99, ACTS 1945 TITLE f y/1 I sr r% li 41 y." ((oie
ANDACTS AMENDATORY THEREOFAND SUPPLEMENT THERETO.
2- 0 Q CLERK TREASURER
DOCUMENT CONTROL NO COPY SIGN AND RETURN TO CLERK'S OFFICE
VOUCHER NO. WARRANT NO.----
ALLOWED 20
IN THE SUM OF
S9 5"
ON ACCOUNT OF APPROPRIATION FOR
(mss -1�
l��I ur2IS 6:�
Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
d materials or services itemized thereon for
which charge is made were ordered and
received except
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund