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184105 04/13/2010 i 1 CITY OF CARMEN., INDIANA VENDOR: 363456 Page 1 of 1 ONE CIVJG SQUARE FILSON EARTHWORK COMPANY, INC CHECK AMOUNT: $158,385.60 i CARMEL, INDIANA 46032 PO BOX 538 NOBLESVILLE IN 46061 CHECK NUMBER: 184105 CHECK DATE: 4!1312010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 902 4460847 1004 -1 137,731.50 1003 -1 LOFTS SUMP PUM 902 4460847 1004 -1 20,654.10 1004 LOFTS SUMP PUMP APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT G702 To: Carmel Redevelopment Comm- Project: Parcel 47 Sump Pump Storm Application No: 1004 -1 Distribution to: 30 W. Main St., Ste 220 110 W. Main St. Carmel, IN 46032 Carmel IN App. Date: February 19, 2010 OWNER CONSTRUCTION MGR. Period to: February 28, 2010 ARCHITECT From: Filson Earthwork Company Inc. []CONTRACTOR PO Box 538 Project Nos: OTHER Noblesville, IN 46061 Contract Date: Contract For: Construction Manager: Keystone Constructon Architect: 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 Application is made for payment, as shown below, in connection with the Contract. completed in accordance with the Contract Documents, that all amounts have been Continuation Sheet, G703, is attached. paid by the Contractor for Work for which previous Certificates for Payment were 1. ORIGINAL CONTRACT SUM 22,949.00 issued and payments received from the Owner, and that current payment show herein is now due. 2. Net Change By Change Orders o.00 3- CONTRACT SUM TO DATE 22 ,949.001 CONTRACTOR: FILSON EARTHWORK COMPANY, INC. 4. TOTAL COMPLETED AND STORED TO DATE 22 ,949.00 13y: Date: February 19, 2010 5. RETAINAGE: reg Ison, President State of: IN a. 1o% of Completed Work 2, 294.90 County of: Hamilton b. 0% of Stored Material 0.00 Subscribed and sworn before me this 19th day of February 2010 Total Retainage N Public: 6. TOTAL EARNED LESS RETAINAGE 20 ,654.10 My Commission expires: 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT 0.00 CERTIFICATE FOR PAYMENT 8. CURRENT PAYMENT DUE 20,654.10 In accordance with the Contract Documents, based on on -site observations and the data comprising this application, the Construction Manager and Architect certify to the Owner 9. BALANCE TO FINISH, INCLUDING RETAINAGE 2,294.90 that to the best of their knowledge, information and belief the Work has progressed as indicated, the quality of the Work is in accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT CERTIFIED. CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS AMOUNT CERTIFIED S '�O, ID Total changes approved in 0.00 0.00 CONSTRUCTION GER: previous months by Owner Total approval this Month 0.00 0.00 By. Date: TOTALS 0.00 0.00 NET CHANGES by Change Order 0.00 ARCHITECT By: Date: This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the TORGO SOFTWARE httpalwww.torgo.net 01996 -2002 ALL RIGHTS RESERVED Contractor named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract. CONTINUATION SHEET G703 PROJECT: Parcel 47 Sump Pump Storm Filson Earthwork Company, Inc. Page 1 of 1 Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing APPLICATION NUMBER: 1004 -1 Contractor's signed Certification is attached. APPLICATION DATE: February 19, 2010 Use Column I on Contracts where variable retainage for line items may apply. PERIOD TO: February 28, 2010 PROJECT NUMBER: A B C D E F G H I Item Description of Work Scheduled Work Completed Materials Total Completed Balance Retainage Value From Previous This Presently and Stored To to Finish Application(s) Period Stored Date SITE DEMOLITION 2,209.00 2,209.00 2,209.00 100% 0.00 220.90 STORM SEWER 16,866.00 16,866.00 16,866.00 100 0.00 1,686.60 GENERAL CONDITIONS 1 3,874.00 3,874.00 3,874.00 100% 1 0.00 387.40 TOTAL: 22,949-001 1 22,949.001 1 22,949.001 100% 1 0.001 2,294.90 A =Line Item Number B =Brief Item Description C =Total Value of Item D =Total of D and E From Previous Application(s) (If Any) E =Total Work Completed For This Application TORGO SOFTWARE http:llv✓mnro.torgo. net ©1996 -2002 ALL RIGHTS RESERVED i AFFIDAVIT AND WAIVER OF LIEN 0 Final 1(_1artial Payment to Follow State of Indiana, County of u SS: 0 1 1 being duly sworn states that he is the of (Name of Officer) C-a oc having contracted with ��A �cOP to furnish certain (Subcontractor /Supplier) (Contractor) materials and /or labor as follows: (Description) for a project known as P►guz` 4-2 -Zr`'`o located at %A a+v L C4­ and owned by and does hereby further state on behalf of the aforementioned subcontractor /supplier: (PARTIAL WAIVER) that there is due from the contractor the sum of Dollars ($'w�o Sy, I O receipt of which is hereby acknowledged, or Q the payment of which has been promised as the sole consideration of this Affidavit and Partial Waiver of Lien which is given solely with respect to said amount, and which waiver shall be effective only upon receipt of payment thereof by the undersigned. (FINAL WAIVER) that the final balance due from the contractor is the sum of Dollars receipt of which is hereby acknowledged, or the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which shall become 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, subject to limitations or conditions expressed herein, if any; and further certifies that no other party has 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. �P'1 B y J Title (Firm) u (Authorized Representative) WITNESS MY HAND AND NOTARIAL SEAL, this vu day of �Noiary Public) My Commission Expires y d I `O Printed Residing in County APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT G702 To: Carmel Redevelopment Comm. Project: Parcel 47 BACKFILL Application No: 1003 -1 Distribution to: 30 W. Main St., Ste 220 110 W. Main St. Carmel, IN 46032 Carmel IN App. Date: February 19, 2010 OWNER CONSTRUCTION MGR. Period to: February 28, 2010 ARCHITECT From: Filson Earthwork Company, Inc. CONTRACTOR PO Box 538 Project Nos: OTHER Noblesville, IN 46061 Contract Hate: Contract For: Construction Manager: Keystone Constructon Architect: 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 Application is made for payment, as shown below, in connection with the Contract. completed in accordance with the Contract Documents, that all amounts have been Continuation Sheet, G703, is attached. paid by the Contractor for Work for which previous Certificates for Payment were issued and payments received from the Owner, and that current payment show 1, ORIGINAL CONTRACT SUM 153,035.00 herein is now due. 2. Net Change By Change Orders 0.00 3. CONTRACT SUM TO DATE 153,035.00 CONTRACTOR: FILSON EARTHWORK COMPANY, INC. 4. TOTAL COMPLETED AND STORED TO DATE 153,035.00 By. /4_ Date: February 19, 2010 5. RETAINAGE: reg Flqon, President State of: IN a. 10% of Completed Work 15,303.50 County of: Hamilton b, o% of Stored Material o.00 Subscribed and sworn before me this 19th day of February 2010 Total Retainage 15,303.50 Notary Public: 6. TOTAL EARNED LESS RETAINAGE 137,731.50 My Commission expires: 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT 0.00 CERTIFICATE FOR PAYMENT 8. CURRENT PAYMENT DUE 137,731.50 In accordance with the Contract Documents, based on on -site observations and the data comprising this application, the Construction Manager and Architect certify to the Owner 9. BALANCE TO FINISH, INCLUDING RETAINAGE 15,303.50 that to the best of their knowledge, information and belief the Work has progressed as indicated, the quality of the Work is in accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT CERTIFIED_ CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS AMOUNT CERTIFIED T 13k 5 V Total changes approved in previous months by Owner CONSTRUCTIO INAGER Total approval this Month By Date: TOTALS 0.00 S 0.00 NET CHANGES by Change Order 0.00 ARCHITECT: By. Date: Z$ to This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the TORGO SOFTWARE hlip. //w forgo net ©1996 -2002 ALL RIGHTS RESERVED Contractor named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract. CONTINUATION SHEET 6703 PROJECT: Parcel 47 BACKFILL Filson Earthwork Company, Inc. Page 1 of 1 Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing APPLICATION NUMBER: 1003 -1 Contractor's signed Certification is attached. APPLICATION DATE February 19, 2010 Use Column I on Contracts where variable retainage for line items may apply. PERIOD TO: February 28, 2010 PROJECT NUMBER. A B C D E F G H I Item Description of Work Scheduled Work Completed Materials Total Completed Balance Retainage Value From Previous This Presently and Stored To to Finish Application(s) Period Stored Date ALT BASEMENT BACKFILL 152,128.001 152,128.001 152,128.00 100% 0.001 15,212.80 ALT GENERAL CONDITION 907.00 907.00 907.00 100% 0.00 90.70 TOTAL: 153,035.00 153,035-001 1 153,035.001 100% 0.001 15,303.50 A =Line Item Number B =Brief Item Description C =Total Value of Item D =Total of D and E From Previous Application(s) (If Any) E =Total Work Completed For This Application TORGO SOFTWARE Nip J lwww.torgo.net 01996 -20 ALL RIGHTS RESERVED T AFFIDAVIT AND WAIVER OF LIEN I Partial �ayment to Follow State of Indiana, County of �A SS: F� L_!� being duly sworn states that he is the R S of (Name of Officer) (Title) having contracted with CP n- 4 X- Qra£VFc.l,)fA,,� C4 W to furnish certain (Subcontractor /Supplier) (Contractor) materials and /or labor as follows: p (Description) for a project known as 4 -C E(- L i located at ��O v� J C4 V- 4 L- and owned by and does hereby further state on behalf of the aforementioned subcontractor /supplier: (PARTIAL WAIVER) that there is due from the contractor the sum of Dollars receipt of which is hereby acknowledged, or the payment of which has been promised as the sole consideration of this Affidavit and Partial Waiver of Lien which is given solely with respect to said amount, and which waiver shall be effective only upon receipt of payment thereof by the undersigned. (FINAL WAIVER) that the final balance due from the contractor is the sum of Dollars receipt of which is hereby acknowledged, or the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which shall become 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, subject to limitations or conditions expressed herein, it any; and further certifies that no other has 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. n C-0 B `v Title S. (Firm} y ilhorized Represeniutive) l o2�i o WITNESS MY HANDAND NOTARIAL SEAL, this day of A (No Public) My Commission FExpires f a I Printed Residing in County 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. ff Payee �1/sQn E d ywnhk b ln�A Purchase Order No. FD 80y 53 Terms c�4 No WC 5 V i l l f 11I Al 460 Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 19-1p OO�f— c� pU sum um 20 6S�.11� 2�1 1003-1 137 731.50 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 j Is on EL\-d6wttk Com IN SUM OF$ p0 �x 53� ,Uladle 4uo )-5 31? 5. 6 o ON ACCOUNT OF APPROPRIATION FOR r Board Members Po #or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s or `02 'H60 L47 'U,65q. 6 bill(s) is (are) true and correct and that the 42 Win- 4 24 137 73 .5t materials or services itemized thereon for which charge is made were ordered and received except 2010 �kJ Slgnature ;director of Redevelopment Cost distribution ledger classification if Title claim paid motor vehicle highway fund