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185031 04/28/2010
CITY OF CARMEL, INDIANA VENDOR: 360381 Page 1 of 1 Q� ONE CIVIC SQUARE SANTAROSSA MOSAIC TILE CO INC CHECK AMOUNT: $13,362.30 CARMEL, INDIANA 46032 PO BOX 664043 INDIANAPOLIS IN 46266 -4043 CHECK NUMBER: 185031 CHECK DATE: 4/28/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 902 4460807 5 13,362.30 PERFORMING ARTS CENTE Document G7021CMa TM -1992 Application and Certificate for Payment Construction Manager Adviser Edition s TO OWNER: l PROJECT: e1 APPLfCATION NO Distribution to: lYll Clv S uU�2 PERIOD TO p3�23�ID' OWNER CONSTRUCTION MANAGER FROM CONTRACTORJ*e CONTRACTOR 14Q &LVIA CONSTRUCTION MANAGER: CONTRACT DATE: 05101Iriq ARCHITECT 11 PROJECT NOS: (,1 )DI 1 1 CONTRACTOR Till IQl10.pbII� T1 X118 VIA ARCHITECT: FIELD C ONTRA C T F Gore l Q IMN It CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and Application is made for payment, as shown below, in connection with the Contract. belief the Work covered by this Application for Payment has been completed in accordance with the Continuation Sheet, AIA Document G703, is attached. Contract Documents, that all amounts have been paid by the Contractor for Work for which previous II �r Certificates for Pay men payments received from the Owner, and that current 1. ORIGINAL CONTRACT SUM payment show n is now due. 2. Net change by Change Orders D• bD CO T QS(l I IBC: 3. CONTRACT SUM TO DATE (Lme .I 2) 4 56. bo Date: Inbo 4. TOTAL COMPLETED STORED TO DATE (Column G on G703) State of::[Il tang 5. RETAINAGE. County of: M(�l t t a• of Corilpleted Work Subscribed a d sw rn to b f re f. (Column D E on G703) me this 22 of b• %o of Stored Material Notary Publ c: (Column F on G703) My Comnli io e es: Total Retainage (Lines 5a 5b or Total in Column I of G703)., I� I CERTIFI ATE FOR PAYMEN In accordance with the Contract Documents, based on on -site observations and the data comprising 6. TOTAL EARNED LESS RETAINAGE I QG5g4.80 this application, the Construction Manager and Architect certify to_the Owner that to the best of their (Line 4 Less Line 5 Total) n knowledge, information and belief the Work has progressed as indicated, the quality of the Work is in 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT qb, /t�J�.SD accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT (Line 6 from prior Certificate) CERTIFIED. 8. CURRENT PAYMENT DUE.. AMOUNT CERTIFIED Z �3 3� 9. BALANCE TO FINISH, INCLUDING RETAINAGE (Attach explanation if amount certified differs from ie mount applied. Initial all figures on this Application and on to Continuati6n Sheet that a e ch nged to conform with the amount certified.) (Line 3 less Line 6i) 1�J�t8� CONS UCTION AN GE By: Date: 1 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHI CT Total changes approved in previous months by Owner By: Date: Z Total approved this Month This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor TOTALS named herein. Issuance,' payment and acceptance of payment are without prejudice to any rights of NET CHANGES by Change Order the Owner or Contractor under this Contract. CAUTION: You should sign an original AIA Contract Document, on which this text appears in RED. An original assures that changes will not be obscured. r AIA Document G702 /CMall x1992. Co e i Copyright ©1992 by The American Institute of Architects. All rights reserved. WARNING: This AIA Document is protected by U.S. Copyright Law and International Treaties. U Unauthorized reproduction or distribution of this AIA Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. i; Purchasers are permitted to reproduce ten (10) copies of this document when completed. To report copyright violations of AIA Contract Documents, e -mail The American Institute of Architects' legal counsel, copyright @aia.org. PIT Document G702/CMa 1992 Instructions Application and Certificate for Payment Construction Manager Adviser Edition A. General Information AIA Document G7021CMa, Application and Certificate for Payment, Construction Manager Adviser Edition, is to be used in conjunction with AIA Document G703, Continuation Sheet. These documents are designed to be used on a Project where a Construction Manager is employed as an adviser to the Owner, but not as a constructor, and where multiple Contractors have direct Agreements with the Owner. Procedures for their use are covered in AIA Document A201 /CMa, General Conditions of the Contract for Construction, Construction Manager Adviser Edition, 1992 Edition. B. Reproductions This document is a copyrighted work and may not be reproduced or excerpted from without the express written permission of the AiA. There is no implied permission to reproduce this document, nor does membership in The American Institute of Architects confer any further rights to reproduce this document. The AIA hereby grants the purchaser a limited license to reproduce a maximum of ten copies of a completed G702lCMa, but only for use in connection with a particular project. The AIA wili not permit reproduction outside of the limited license for reproduction granted above, except upon written request and receipt of written permission from the AIA. Rights to reproduce the document may vary for users of AIA software. Licensed AIA software users should consult the End User License Agreement (EULA). To report copyright violations of AIA Contract Documents, e -mail The American Institute of Architects' legal counsel, copyright @aia.org. C. Completing the G702/CMa Form After the Contractor has completed AIA Document G703, Continuation Sheet, summary information should be transferred to AIA Document G702 /CMa, Application and Certificate for Payment, Construction Manager- Adviser Edition, The Contractor should sign G702 /CMa, have it notarized and submit it, together with G703, to the Construction Manager and Architect. The Construction Manager and Architect should review G702 /CMa and G703 and, if they are acceptable, complete the Certificate for Payment on G702 /CMa. The Construction Manager and Architect may certify a different amount than that applied for pursuant to Sections 9.5 and 9.6 of A201 /CMa. They should then initial all figures on G7021CMa and G703 that have been changed to conform to the amount certified and attach an explanation. The completed G7021CMa and G703 should be forwarded to the Owner. D. Completing the G703 Form Heading: This information should be completed to be consistent with similar information on AIA Document G7021CMa, Application and Certificate for Payment, Construction Manager- Adviser Edition. Columns A, B C: These columns should be completed by identifying the various portions of the Project and their scheduled value consistent with the schedule of values submitted to the Architect at the commencement of the Project or as subsequently adjusted. The breakdown may be by sections of the Work or by Subcontractors and should remain consistent throughout the Project. Multiple pages should be used when required. Column C should be subtotaled at the bottom when more than one page is used and totaled on the last page. Initially, this total should equal the original Contract Sum. The total of column C may be adjusted by Change Orders during the Project. Column D: Enter in this column the amount of completed work covered by the previous application (columns D E from the previous application). Values from column F (Materials Presently Stored) from the previous application should not be entered in this column. Column E: Enter here the value of Work completed at the time of this application, including the value of materials incorporated into the project which were listed on the previous application under Materials Presently Stored (column F). Column F: Enter here the value of Materials Presently Stored for which payment is sought. The total of the column must be recalculated at the end of each pay period. This value covers both materials newly stored for which payment is sought and materials previously stored which are not yet incorporated into the Project. Mere payment by the Owner for stored materials does not result in a deduction from this column. Only as materials are incorporated into the Project is their value deducted from this column and incorporated into column E (Work Completed This Period). Column G: Enter here the total of columns D, E and F. Calculate the percentage completed by dividing column G by column C. Column H: Enter here the difference between column C (Scheduled Value) and column G (Total Completed and Stored to Date). Column I: This column is normally used only for contracts where variable retainage is permitted on a line -item basis. It need not be completed on projects where a constant retainage is withheld from the overall contract amount. Change Orders: Although Change Orders could be Incorporated by changing the schedule of values each time a Change Order is added to the Project, this is not normally done. Usually, Change Orders are listed separately, either on their own G703 form or at the end of the basic schedule. The amount of the original contract adjusted by Change Orders is to be entered in the appropriate location on the G7021CMa form. Construction Change Directives: Amounts not in dispute that have been included in Construction Change Directives should be incorporated into one or more Change Orders. Amounts remaining in dispute should be dealt with according to Section 7.3 in A201 /CMa. E. Making Payment r. The Owner should make payment directly to the Contractor based on the amount certified by the Construction Manager arrd'.Architect on AIA Document G702 1CMa, Application and Certificate for Payment, Construction Manager- Adviser Edition. The completed form contains the name As ddress of the Contractor. Payment should not be made to any other party unless specifically indicated on G702 /CMa. AIA Document G702 /CMaTM 1992. Copyright 1992 by The American tnstitute of Architects. A!I rights reserved. WARNING: This AIA Document is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this Ale Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. Purchasers are permitted to reproduce ten (10) copies of this document when completed. To report copyright violations of AIA Contract Documents, e -mail The American Institute of Architects' legal counsel, copyright@aia.org. 09201 CONTINUATION SHEET AIA DOCUMENT 6703 (Instructions on reverse side) PAGE 2 OF 2 PAGES AIA Document 6702, APPLICATION AND CERTIFICATE FOR PAYMENT. APPLICATION NO.: 5 containing Contractor's signed Certification, is attached. APPLICATION DATE; 3/15/2010 In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 3/23/2010 Use Column I on Contracts where variable retainage for line items may apply ARCHITECT'S PROJECT NO.: A B C D F F G H I WORK COMPLETED MATERIALS TOTAL BA1•ANCE ITEM[ SCHEDULED PRESENTLY COMPLETED o RETAINAGF, NO. DESCRIPTION OF WORK VALUE PROM PREVIOUS STORED AND STORED 10 (IF VARIABLE) APP LICATION THIS PERIOD (NOT IN TO DATE (G C) FINISH RATE) (D E) D OR E) (D +ELF) (C G) 01.00 STONE FLOORING 01.10 MATERIAL 402,325.00 90,000.00 90,000.00 22 312,325.00 9,000.00 01.20 LABOR 349,950.00 13,750.00 7,247.00 20,997.00 6 328,953.00 2,099.70 01.30 01.40 STONE TOPS 01.50 MATERIAL 20,000.00 2,000.00 2,000.00 10 18,000.01 200.00 01.60 LABOR 28,000.00 5,600.00 5,600.00 20 22,400.00 560.00 01.70 01.80 QUARRY TILE 0 1,90C MATERIAL 1,500.00 1,500.0 02.00c LABOR 1,500.00 1,500.0 02.10 02.20C GENERAL ALLOWANCE 35,000.00 35,000.0 02.30 CAD AS -BUILT ALLOWANCE 5,000.00 5,000.0 03.40 BOND 3,175.00 3,175.00 3,175.00 100 317.5 03.50 03.60 CHANGE ORDER #1 03.70 846,450.0 106,925.0 14,847.0 121,772.00 14 724,678.0 12,177.2 mm AIA DOCUMENT G703 CONTINUATION SHEET FOR G702 1992 EDITION AIA° ©1992 THE AMERICAN INSTITUTE OF ARCHITFCTS, 1735 NEW YORK AVENUE, N. \w., WASI-IiNGTON, D.C. 20006 -5292 WARNING: Unlicensed photocopying violates U.S. copyright laws and will subject the violator to legal prosecution. G703-1992 t CAUTION: You should use an original AIA document which has this caution printed in red. An original assures that changes will not be obscured as may occur when documents are reproduced. WAIVER OF LIEN AND AFFIDAVIT O FINAL (v) PARTIAL PAYMENT TO FOLLOW being duly sworn states that (s) he is of SANTAROSSA MOSAIC TILE CO., INC. having contracted wit lel S&tW to furnish certain materials and /or labor as f ollows 6QQn y, Udu. TA A for a project known as kw located at C0901 NOW and owned b Abldoes hereby further state on behalf of the aforementioned sub /contractor /supplier. PARTIAL n WAIVER That the balance due from the contractor is the sum of: lf UUW �f Gbk y DOLLARS 1bH.60 (v) Receipt of which is hereby acknowledged: or Payment of which has been promised as the sole consideration for this AFFIDAVIT AND WAIVER OF LIEN (PARTIAL) which is given to and for said amount effective upon receipt of such payment. FINAL WAIVER That the final balance due from the contractor is the sum of: DOLLARS O Receipt of which is hereby acknowledged: or O Payment of which has been promised as the sole consideration for this AFFIDAVIT AND WAIVER OF LIEN (FIN_ AL) which is given to and for said amount effective upon receipt of such payment. THEREFORE: the undersigned waives and releases unto the said owner of said premises any and all lien or claim whatsoever on the above described property and improvements thereon on account of labor and.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 performed or material furnished to the undersigned for said project, and within the scope of this AFFIDAVIT and WAIVER. SANTAROSSA MOSAIC TILE CO., INC. BY: TITLE: WITNESS y hand and notarial seal this day of 20 1 D My Commission Expires: 1 itu a a _"W t y Pu lic /J Residing in Marion, County of Indiana Printed Prescribed by State Board of Accounts City Form No. 201 (Rev. 1985) 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 S97 �erG ys 9 �O'`- T1, Purchase Order No. 2 7a Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 1 2 5 13 362 -30 h Total 362- 30 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 -1.8. 20 Clerk- Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF 36.2.0 ON ACCOUNT OF APPROPRIATION FOR Board Members Po# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or jay S 4W OS0 13 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 201D Di r e ctor o 88(tgpment Cost distribution ledger classification if Title claim paid motor vehicle highway fund