186680 06/21/2010 CITY OF CARMEL, INDIANA VENDOR: 362780 Page 1 of 1
ONE CIVIC SQUARE LITHKO CONTRACTING
CHECK AMOUNT: $18,546.80
CARMEL, INDIANA 46032 PO Box 270
4 MONROE OH 45050
�o CHECK NUMBER: 186680
CHECK DATE: 6/2112010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
902 4460807 APP 3 18,546.80 PERFORMING ARTS CENTE
APPLICATION AND CERTIFICATE FOR PAYMENT CONSTRUCTION MANAGER- ADVISER EDITION
AIA DOCUM. ENT G7021CMa PAGE ONE OF PAGES
TO OWNER: PROJECT: CPAC RETAINING APPLICATION NO: 3 RETAINER REQUEST Distribution to:
CITY OF CARMEL, REDEVELOPMENT COMMISSION WALL PERIOD TO: March 3.1, 201.0 FIOWNER
ONE CIVIC SQUARE PROJECT NO: 3658 -7300 CONSTRUCTION
CARMEL, IN 46032 BCCI JOB# L5592 MANAGER
FROM CONTRACTOR: CHECKREM17T,4NCE::ADDRESS. CONTRACT DATE: ARCHITECT
LITHKO CONTRACTING, INC. LITHKO CONTRAGTING,;INC.. 7CONTRACTOR
P.O. BOX 270 P.O. BOX 270'
MONROE, 01 45050 MONROE; OHIO 45050
VIA CONSTRUCTION MANAGER: SHIEL SEXTON CO., INC
CONTRACT FOR: Place /Finish Concrete VIA ARCHITECT: CSO ARCHITECTS INC
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 176.000.00
2. Net change by Change Orders 9,468.00 CONTRACTOR: LITHKO CONTRACTING, INC.
3. CONTRACT SUM TO DATE (Line I t 2) 185,468.00
4. TOTAL COMPLETED STORED TO DATE 185.468.00 RY P
(Column G on G703) By: Date: March 10, 2010
5. RETAINAGE: A A A N, ,➢TOR
a. 0 of Completed Work 0.00 State of: of: WARREN
(Column D E on G703) Subscribed and sworn to b lE ADE�[areh, 2010.
b. of Stored Material Notary Public: otary "!c,state
vv p (Column F on 0703) My Commission expc s: Total Retainage (Lines 5a+ 5b or �O A ;miwf n
Total in Column I of G703) 0.00 ZERTWMWITTOWPAYM EN y
6. TOTAL EARNED LESS RETAINAGE 185,468.00 In accordance with the Contract Documents, based on on -site observations and the data
(Line 4 less Line 5 Total) comprising this application, the Construction Manager and Architect certify to the
7. LESS PREVIOUS CERTIFICATES FOR Owner that to the best of their knowledge, information and belief the Work has
PAYMENT (Line 6 from prior Certificate) 166,921.20 progressed as indicated, the quality of the Work is in accordance with the Contract
8. CURRENT PAYMENT DUE 18,546.80 Documents, and the Contractor is entitled to payment ofthe AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE 0.00 1 5q(
Line 3 less Line 6 AMOUNT CERTIFIED `p
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation ifamount certified differs ni the amount applied for. Initial all
ota changes approve figures on this Ap I' tion and on the Conti at ort sheet that changed to conform to the
in revious months by Owner $9,468.00 $0.00 amount certified
CO TRUCTI AGER: EL 5 �X N CO., INC.
Total approved this Month $0.00 $0.00 By: Date:
A C CHITEC S INC.
TOTALS $9,468.00 $0.00 By: Date:
NET CHANGES by Change Order $9,468.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
Contractor named herein. Issuance, payment and acceptance of payment are without
prejudice to any rights of the Owner or Contractor under this Contract.
e c a-
THE AMERICAN INSTITUTE OF ARCHITECTS, 1745 NEW YORK AVE., N.W., WASHINGTON, DC 20006 -5292
Users may obtain validation of this document by requesting of the license a completed AIA Document D401 Certification of Document's Authenticity
CONTINUATION SHEET AIA DOCUMENT G703 PAGE OF PAGES
AIA Document G702, APPLICATION AND CERTIFICATION FOR PAYMENT, containing APPLICATION NO: 3 RETAINER REQUEST
Contractor's signed certification is attached. APPLICATION DATE: 3/10/2010
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 3/31/2010
Use Column l on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO: 3658 -7300
CPAC RETAINING WALL
5592 CONtNACTINO, INC.
A B C D E F G II 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 MOBILIZATION JOB SETUP 10,000.00 10,000.00 0.00 0.00 10,000.00 100% 0.00 $0.00
2 PAYMENT PERFORMANCE BOND 2,000.00 2,000.00 0.00 0.00 2,000.00 100% 0.00 $0.00
3 FOUNDATIONS 34,000.00 34,000.00 0.00 0.00 34,000.00 100% 0.00 $0.00
4 RETAINING WALLS 80,000.00 80,000.00 0.00 0.00 80,000.00 100% 0.00 $0.00
5 BACKFILL 45,000.00 45,000.00 0.00 0.00 45,000.00 100% 0.00 $0.00
6 ALLOWANCE 5,000.00 5,000.00 0.00 0.00 5,000.00 100% 0.00 $0.00
CO #1 9,468.00 9,468,00 0.00 0.00 9,468.00 100% 0.00 $0.00
0.00 0.00 0.00 0.00 0.00 0% 0.00 $0.00
0.00 0.00 0.00 0.00 0.00 0% 0.00 $0.00
0.00 0.00 0.00 0.00 0.00 0% 0.00 $0.00
0.00 0.00 0.00 0.00 0.00 0% 0.00 $0.00
0.00 0.00 0.00 0.00. 0.00 0% 0.00 $0.00
0.00 0.00 0.00 0.00 0.00 0% 0.00 $0.00
0.00 0.00 0.00 0.00 0.00 0% 0.00 $0.00
0.00 0.00 0.00 0.00 0.00 0% 0.00 $0.00
0.00 0.00 0.00 0.00 0.00 0% 0.00 $0.00
0.00 0.00 0.00 0.00 0.00 0% 0.00 $0.00
0.00 0.00 0.00 0.00 0.00 0% 0.00 $0.00
0.00 0.00 0.00 0.00 0.00 0% 0.00 $0.00
0.00 0.00 0.00 0.00 0.00 0% 0.00 $0.00
0.00 0.00 0.00 0.00 0.00 0% 0.00 $0.00
0.00 0.00 0.001 0.00 0.00 1 0% o.00 i $0.00
GRAND TOTALS 185,468.00 185,468.001 6.00 0.00 185,468.00 1 100%1 0.00 $0.00
Users may obtain validation of this document by requesting of the license a completed AIA Document D401 Certification of Document's Authenticity
Page 1 of I JMP92 -20 -F Effective- 1 /31 /01
s
CONSENT OF SURETY ONVNFR
TO FINAL PAYMENT ARCHITECT Cl
CONTRACTOR 0
AIA Docu)nent G707 SURETY 0
(Instructions on revel :tie side) Bond NO. 33BCSFL091I OTHER 11
TO OWNER: ARCHITECT'S PROJECT NO,:
(Nrunr tool udrGrcc)
City of Carmel
One Civic Square CONTxACI'FOR: Retaining wall and foundation
Carmel, IN 46032 work for Parcel 7A
PROJECT: CONTRACT UA'I *ED:
(New+e rind arlrGtKN)
Regional Performing Arts Center
In accordance with the provisions of the Contmct between the Owner ind the Contractor as indicated alxwe, the
1111sert name anti arldn'.c" of.yvm'ro
Hartford Fire Insurance Company
One Hartford Plaza
Hartford, CT 061.55
SURIiTY,
on boncl of
(buerY umue cure) udrhz^.cr of C.rurh nclu+7
Lithko Contracting, Inc.
7706 M o_ller Road
Indianapolis, IN 46268
CONTRACTOR,
hereby 1tl)pr0ve4 Of dte final payment to the Convactor, anti agrees that final payment to the Contractor shall not relieve the Surety of
any of its obligations to
(1 naerY name a +ul adrlrt:a ujOu vrer7
City of Carmel
One Civic Square
Carmel, IN 46032
OWNER,
XS set forth in said Surety's bond.
IN WITNESS WI•ILREOC, the Surety has hereunto set Its hand on this date: March 24, 20
(hutuY hr rrd(hig the mwubfullauv:d br A ouanaiic title aad reKrr.)
Hartford Fire Insurance Company
(Gnzrt7
BY 0—t
(5ignarr�rt +rjrurllx�rkxKl rt /as:arrrruhe9
Attest:
(Seri): S usan A. Yeazell Attorney -in -Fact
(P�drrlrrl+unuc tool tide!
Surety Phone No. 5 13- 333 -205 1
AIA DOCUMENT G707 CONSPNTOFSI'H{:lY'I"O FWAI. FAYMF.N r 1194 EDITION 'AIA
1 f1 1914 'Rir A.1ir AY INSC17UlT OF AE2CIi11T:GT5, 1 735 KF. \V YURK AVF.NUIi, MI. YC'Atil
ING7On, D.G. 29006.5292 G707 -1994
Direct inquiries /Clairns tc:
0 TW ER THE HARTFORD
N,
ATTO sonl�, T-4
P,O. BOX 2103, 690 ASYLUM AV
HART FORD, CONNECTICUT 061 5)
cal?: BBS -266 -34BB br fax: 86C- 757 -55?5
KNOW ALL P =RSORS BY THESE PRESENTS THAT;
Agency Code: 33 33
Hartford Fire Insurance Company, a comoration duly organized under the jaws or the State of Connecticut
Hartford Casualty insurance Company, a corporation duly organized under the laws of the Siatc of Indiana
k Hartford Accident and indemnity Company, a comoration duly organized under the laws of the Statt of Connecticut
'Hartford Underwriters Insurance Company, a cor duly organized under the laws of the State of Connecticut
Twin City Fire Insurance Company, a corporation duly organized under the laws of the State of Indiana
Hartford insurance Company of Illinois, a comoration duly organized under the laws of the State of Illinois
Hartford insurance Company.of the Midwest, a comoration duly organized unde -the laws of the State ofindiana
Hartford Insurance Company of the Southeast, a corporation duly organized under the laws of the State of Fiorida
having their home office in Hartford, Connecticut, (hereinafter collectively referred to as the "Companies do hereby make, constitute and appoln:,
uP to the amount of unlimited:
Susan A. Yeazell, Dan E. Ries of Cincinnati, OH;
Deb lvfarkland, Kimberly D. Richards, Michael D. Ward, Dayton OH
their true and lawful Attorney(s) -in -Fact, each in their separate capacity if more than one is named abcve, to sign its name as surety(es) only as
delineated above by Z, and to execute, seal and acknowledge any and all bonds, undertakings, contracts and othr written Instruments in the
nature thereof, on behalf of the Companies in their business of guaranteeing the fidelity of persons, guaranteeing the performance of contracts and''
executing or guaranteeing bonds and undertakings requi or permitted in any actions or proc allowed by law.
In Witness Whereof, and as authorized by a Resolution of the Board of Directors of the Companies on January 22, 200= the Companies
have caused these presents to be signed by its Assistant Vice President and its corporate seais to be hereto affixed, duly attested by its Assistan:
Secretary. Further, pursuant to Resolution of the Board of Directors of the Companies, the Companies hereby unambioucusly affirm that they are
and will be bound by any mechanically applied sionatures applied to this Power of Attorney.
yTT IV r to Xt t +f r�.
y OL 4
jr �AMt Sig '�'r` c un� a ti.��'P g 't ,y; A y�,,Kpootn 'e<
i r L1P.7 C x °t {e r _'S I
iii a +.r,tav,`" �•owp.� 1 g i 4 G AF`
4 'jet ;�aL w�...1� r'r,�\ rr
Scot; Sadowsky, Assistant Secretary M. Ross Fisher, Assistant Vice President
STATE OF CONNECTICUT
�s. Hartford
COUNTY OF HARTFORD
On this 3rd day of March, 2008, before me personally came M. Ross Fisher, to me known, who being by me duly sworn, did depose and
say: that he resides in the County of Hartford, State of Connecticut; that he is the Assistant Vice President of the Companies, the corporations
described in and which executed the above instrument; that he knows the seals of the said corporations; that the seals affixed to the said
instrument are such corporate seats; that they were so affixed by authority of the Boards of Directors of said corporations and that he signed his
name thereto by like authority.
E. p
t+Ar y f
�f Scott E. Paseka
Notary Public
CERTIFICATE My Commission Expires October 31,2N2
I, the undersigned, Assistant Vice President of the Companies, DO HEREBI' CRTIFY that the above and foregoing is a true and correct
copy of the Power of Attorney executed by said Companies, which is still in full force effe.;tive as of March 24 20
Signed and sealed at the City of Hartford.
�S7Y J�� 40
Gary W. Stumper, Assistant Vice President
WAIVER OF LIEN
LITHKO CONTRACTING, INC. the Prime Contractor, having a Contract with CITY
OF CARMEL for the PLACE FINISH CONCRETE work situated on or around or in front of the following
described property:
Project: CPAC RETAINING WALL
Address: 211 CITY CENTER DRIVE, CARMEL, IN 46032
Owner: CITY OF CARMEL, REDEVELOPMENT COMMISSION
has performed work and /or furnished Labor, Services, Materials, Equipment, or Machinery for the Project and
waives, releases and surrenders any claim, lien or right of lien for all work, labor, materials, equipment,
machinery and services provided by the Prime Contractor through the period for which payment was received
from CITY OF CARMEL in the amount of 125, 100.00
Prime Contractor further states that no other person has any rights to a lien or claim against the Contractor or
the Owner on account of work, labor or services performed or material, equipment or machinery furnished to
the Prime Contractor for this project through the period for which payment was received from
CITY OF CARMEL in the amount of 125,100.00
The undersigned further certifies that he /she is authorized to sign this lien waiver and that this document is
being executed and signed completely free of duress or harassment.
I, J. ANITA BUCHEIT being BILLING ADMINISTRATOR of
it e
LITHKO CONTRACTING, INC. acknowledge the foregoing in full and certify that this is a true and accurate
statement.
Executed this 24TH day of MARCH _,20 10
9
(Signature)
State of OHIO
County of WARREN
Subscribed and sworn to before me this 24TH day of MARCH 20 10
p.R „U
A; E E. YERKE S
m S ate of Ohio
ass My Commission Expires
May 21, 2014
ti No. 2009 -RE- 26324
0
w�
`prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
CITY OF CARMEL
ri
An invoice or bill to be properly itemized mu §t: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
G� KU ivy Ii l �i� c Purchase Order No.
Terms
r7p %rG�� Ofd �f5 DSG Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
a 3 SYGS
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
16y1,7,hK IN SUM OF
l 0k 2 7G
�oh rr�,� Uf/ �I SUS�
ON ACCOUNT OF APPROPRIATION FOR
Pay from TIF J I 10
Board Members
PO# or D PT. INVOICE NO. ACCT #/TITLE AMOUNT I hereby certify that the attached invoice(s), or
qeh 2 7 l9 S �K!�D bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
fr received except
S_ 20/,:::)
Signature
Director of Redevelopment
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund