185846 05/26/2010 a CITY OF CARMEL, INDIANA VENDOR: 362780 Page 1 of 1
i ONE CIVIC SQUARE LITHKO CONTRACTING CHECK AMOUNT: $10,822.50
1, CARMEL, INDIANA 46032 PO BOX 270
MONROE OH 45050 CHECK NUMBER: 185846
CHECK DATE: 5/26/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
902 4460805 APP 4 10,822.50 CITY CENTER
A PPLICATION AND CERTIFICATION FOR PAYMENT AM DOCUMENT G702 PAGE ONE OF PAGES 4
TO O`x-.;'NE PROJECT: CARMEL CITY APPLICATION NO: 4 Distribution to:
CITY OF CARMEL, REDEVELOPMENT CONIMISSIC CENTER PHASE 1 PERIOD TO: June 30, 2009 OWNER
1 1 I WEST AMIN ST., SUITE 180 PROJECT NOS: ARCHITECT
CARMEL, IN 46032 LCI JOB# L5429 CONTRACTOR
FROM CONTRACTOR: CHECK REMITTANCE ADDRESS: CONTRACT DATE: e
LITHKO CONTRACTING, INC LITHKO CONTRACTING, INC.
P.O. BOX 270 E.O. BOX 270
MONROE, OHIO 45050 MONROE, OHIO 45050
CONTRACT FOR: Place /Finish Concrete VIA ARCHITECT:
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigndd'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 436,000.00
2. Net change by Change Orders 26,001.16 CONTRACTOR: LITHKO CONTRACTING, INC.
3. CONTRACT SUM TO DATE (Line 1 2) 462,001.16
4. TOTAL COMPLETED STORED TO 462,001.16
DATE (Column G on G703) By: Date: ,Tune 18, 2009
5. RETAINAGE: ANDREA GANIk l f ,COORDINATOR
a. 10% of Completed Work 46,200.12 State of: I Ih11Q County of: WARREN
(Column D E on G703) Subscribed andiswoY b aYie fftyts' IS day of June, 2009
b. of Stored Material NN H
(Column F on G703) Notary Publi
Total Retainage (Lines 5a 5b or My Commis
Total in Column I of G703) 46,200.12 ARCHITECT fFO AYME
6. TOTAL EARNED LESS RETAINAGE 415,801.04 In accordance with the' C'dn(racfDocuments, based on on -site observations and the data
(Line 4 Less Line 5 Total) comprising the application, the Architect certifies to the Owner 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) 404,978.54 the quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE 10,822.50 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE 46,200.12
(Line 3 less Line 6) AMOUNT CERTIFIE Iii 522 d
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanat' n if nount certified differs from the amount applied. Initial all figures on this
Total changes approved Application an onthe Continu Sheet that are changed to conform with the amount certified.)
in previous months by Owner $26,001.16 $0.00 ARCHITECT
Total approved this Month $0.00 $0.00 By: Da
TOTALS $26,001.16 $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
NET CHANGES by Change Order $26,001.16 prejudice to any rights of the Owner or Contractor under this Contract.
AIA DOCUMENT G702 APPLICATION AND CERTIFICATION FOR PAYMENT- 1992 EDITION AIA ®1992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE., N.W., WASHINGTON, DC 20006 -5292
Users may obtain validation of this document by requesting a completed AIA Document D401 Certification of Document's Authenticity from the Licensee.
JMI'92 -22 -F Effective- 1 /3] /01
Page 1 of 1
CONTINUATION SHEET Ara DOCUMENT G703 PAGE OF PAGES
AIA Document G702, APPLICATION AND CERTIFICATION FOR PAYMENT, containing APPLICATION NO: 4
Contractor's signed certification is attached. APPLICATION BATE: 6/18/2009 In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 6/30/2009
Use Column I on Contracts where variable retainage For line items may apply. ARCHITECT'S PROJECT NO:
CARMEL CITY CENTER PHASE i Efthkp
L54
A B C D E F G H I
ITEM DESCRIPTION OF WORK SCHEDULED WORK COMPLETED MATERIALS TOTAL BALANCE RETAINAGE
NO, VALUE FROM PREVIOUS THIS PERIOD PRESENTLY COMPLETED (G C) TO FINISH (IF VARIABLE
APPLICATION STORED AND STORED (C G) RATE)
(NOT IN TO DATE
D OR E) (D +E +F)
1 PAYMENT PERFORMANCE BOND 4,800.00 4,800.00 0.00 0.00 4,800.00 100% 0.00 $480.00
2 MOBILIZATION 5,000.00 5,000.00 0.00 0.00 5,000.00 100% 0.00 $500.00
3 GENERAL CONDITIONS LAYOUT 5,000.00 5,000.00 0.00 0.00 5,000.00 100% 0.00 $500.00
4 FIRESTOPPING 12,000.00 12,000.00 0.00 0.00 12,000.00 100% 0.00 $1,200.00
5 LIGHT POLE BOLLARD PEDESTALS 20,000.00 20,000.00 0.00 0.00 20,000.00 100% 0,00 $2,000.00
6 MOTOR COURT REBAR INSTALLATION 11,375.00 11,375.00 0.00 0.00 11,375.00 100% 0.00 $1,137.50
7 MOTOR COURT REBAR MATERIALS 38,500.00 38,500.00 0.00 0.00 38,500.00 100% 0.00 $3,850.00
8 MOTOR COURT PREP, PLACE FINISH 88,800.00 88,800.00 0.00 0.00 88,800.00 100% 0.00 $8,880.00
9 VETERANS WAY REBAR INSTALLATIO 6,500.00 6,500.00 0.00 0.00 6,500.00 100% 0.00 $650.00
10 VETERANS WAY REBAR MATERIALS 21,750.00 21,750.00 0.00 0.00 21,750.00 100% 0.00 $2,175.00
VETERANS WAY PREP, PLACE FINISH 49,600.00 49,600.00 0.00 0.00 49,600.00 100% 0.00 $4,960.00
HANOVER SQ REBAR INSTALLATION 6,500.00 6,500.00 0.00 0.00 6,500.00 100% 0.00 $650.00
HANOVER SQ REBAR MATERIALS 21,750.00 21,750.00 0.00 0.00 21,750.00 100% 0.00 $2,175.00
HANOVER SQ PREP, PLACE, FINISH 49,600.00 49,600.00 0.00 0.00 49,600.00 100% 0.00 $4,960.00
COURT PLAZA REBAR INSTALLATION 6,500.00 6,500.00 0.00 0.00 6,500.00 100% 0.00 $650,00
COURT PLAZA REBAR MATERIALS 21,750.00 21,750.00 0.00 0.00 21,750.00 100% 0.00 $2,175.00
COURT PLAZA PREP, PLACE FINISHI 49,600.00 49,600.00 0.00 0.00 49,600.00 100% 0.00 $4,960.00
RE MOB FOR CRANE AREA REBAR INSTALL 1,625.00 0.00 1,625.00 0.00 1,625.00 100% 0.00 $162.50
REMOB CRANE AREA REBAR MATERIALS 4,950.00 4,950.00 0.00 0.00 4,950.00 100% 0.00 $495.00
REMOB CRANE AREA PREP, PLACE, FINISH 10,400,00 0.00 10,400.00 0.00 10,400.00 100% 0.00 $1,040.00
CO #I ASI #1 2 DRAWING REVISION 3,315.87 3,315.87 0.00 0.00 3,315.87 100% 0.00 $331.59
CO #2 AST #3, #4 ESI 16 CHANGES 22,685.291 22,685.291 0.00f 0.00 22,685.29 100% 0.00 $2,268.53
GRAND TOTALS 462,001.16 449,976.161 12,025.00 0.00 462,001.16 100% 0.00 $46,200.12
Users may obtain validation of this document by requesting of the license a completed AEA Document D401 Certification of Document's Authenticity
Page 1 of 1 JMP92 -20 -F Effective -1 /31/01
SUBCONTRACTOR'S SWORN STATEMENT OF
INDEBTNESS WAIVER OF LIEN
STATE OF Indiana
COUNTY QF Hamilton
Being duly sworn upon his /her oath disposes and
says that:
1. He /she is (inserting sole proprietor, partner or corporate office held, as the case maybe),
of Lithko Contracting hereafter called the "Subcontractor He /she is over the age of twenty -one.
He /she is authorized to make this affidavit on behalf of Subcontractor.
2. Subcontractor is the GON)C TE Subcontractor for the construction of the development known as
CARMEL CITY CENTER located in CARMEL (City), INDIANA (state), hereafter referred to as the
"Development pursuant to the contract between the Subcontractor and Signature Construction, LLC,
the General Contractor.
3. This affidavit is made for the express purpose of inducing Signature Construction, LLC, to make
payment to Subcontractor of the invoice submitted herewith for labor and materials furnished pursuant to
said Contractor. Upon receipt of said payment the Subcontractor hereby waives any lien rights to which
Subcontractor is entitled for labor or materials furnished for the development to the date hereof.
4. Listed below are all suppliers or other persons who either has furnished or might furnish the
Subcontractor with materials, appliances, machinery, fixtures or furnishing placed upon or installed on the
development. Mark (X) in the appropriate column for EACH supplier listed. Place an (X) in column: 1) If a
waiver of lien by supplier conditioned by payment of a specified amount is attached hereto. (In this case
also show the amount owed the supplier). 2.) If a FULL (final) lien release has been signed and delivered
to the General Contractor. 3.) If the initial delivery has not been made.
S upplier List (Add list if necessary 1. Amount Owed 3
5 &v0 MA ,S 0 a.446 c2,-_%F_- o L- A
Ct tF_ `Loo E1, 1 V c of o
#1 and 2 correspond to the same numbered choices on the waiver format. Signature Construction, LLC
is hereby authorized to make payment to each such unpaid creditor either directly or by check jointly
payable to Subcontractor and such creditor, as Signature Construction, LLC shall determine.
5. There are no bills, charges, costs or expenses for labor or material which could now or hereafter result
in lien being filed against the Development or a claim being asserted against the General Contractor
except the persons or businesses named in Paragraph 4 above.
IN WITNESS WHERE OF, affiant has signed this document on behalf of the Subcontractor this
day of A L_ 2 JC
(Authori ed kepresentativef Subcontractor)
County of E!✓
State o
Subscribed and sworn to before me, a Notary Public in and for said Cou
This
9 Day of L- f, Z 2
4
X ce, (N ot ry Public o
(Printed Name)
My Commission Expires:
NOTARY SEAL MUST APPEAR ON THIS FORM. (Revised 101200
6
.Lithi o Contracting, Inc.
1513} 539 -4144 y
Remittance Address
P.O. BOX 270
CONTRACTING INC.
MONROE, OHIO 45050 s
149837
TO: CITY OF CARMEL, REDEVELOPMENT COMMISSION
111 WEST AMIN ST., SUITE 180 Invoice No.
CARMEL, IN 46032 26640 777R71]
C/O SIGNATURE CONSTRUCTION, LLC.
720 THIRD AVE., S.W. Invoice Date
CARMEL, IN 46032 6/18/09
Job name: Lithko Job No. Customer Job No. P.O. No.
CARMEL CITY CENTER PHASE 1 L54
Description Amount
DRAW# 4 GROSS 12,025.00
RET 1 ,202.50
10,822.50
COMMUNICATIONS CONVEYED ON CHECK TENDERED STATING
PAYMENT IN FULL AND /OR WAIVING OF LIEN RIGHTS TO ANY
EXTENT MUST BE SENT TO SELLER AS FOLLOWS:
ATTN: ACCOUNTS RECEIVABLE DEPT., LITHKO CONTRACTING, INC.
P.O. BOX 270, MONROE, OH 45
Payment Terms 30 DAYS TOTAL AMOUNT DUE G, 1.0,822.50
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
L i"7 k b Purchase Order No.
Terms
af�a Ch' ySOSO Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
l? U /a9 4 1 y 5 F22,So
Total lGF22_S�
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.
11 ALLOWED 20
IN SUM OF
PO
1C 3-2,2 5
ON ACCOUNT OF APPROPRIATION FOR
t 1 r NO
Board Members
Po# or INVOICE NOS ACCT #/TITLE AMOUNT I hereby certify that the attached invoice(s), or
DEPT.
9c2 41 y6'61�4o5 1G822,99 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
5 20
Signature
Director of Redevelopment
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund