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HomeMy WebLinkAbout189643 09/14/2010 CITY OF CARMEL, INDIANA VENDOR: 364099 Page 1 of 1 L ONE CIVIC SQUARE CHANCE BROS MARBLE TILE INC CHECK AMOUNT: $72,595.25 CARMEL, INDIANA 46032 114 W MCCARTY ST :o; INDIANAPOLIS IN 46225 CHECK NUMBER: 189643 CHECK DATE: 9/14/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 902 4460807 APP 4 19,800.00 PAC JUNE 902 4460807 APP 5 52,795.25 PAC JULY S l a- 11 A IA TM Document G7021CMa -19.92 Application and Certificate for Payment Construction Manager Adviser Edition �t TO OWNER: PROJECT: APPLICATION NO Distribution to: CITY OF.CARMEL REDEVELOPMENT COMMISSION 1 CIVIC SQUARE PERIOD TO: FOUR OWNER ID CARMEL, IN 46032 CARMEL PERFORMING ARTS 06/15/10 CONSTRUCTION MANAGER El FROM CONTRACTOR: VIA CONSTRUCTION MANAGER: CONTRACT DATE: CERAMIC TILE ARCHITECT Chance Bros. Marble Tile Inc. PROJECT NOS: I 1 CONTRACTOR 114 W. McCarty St., VIA ARCHITECT CSO ARCHETECTS FIELD CONTRACT Onapolis, IN 46225 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 Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Continuation Sheet, AIA Document G703, is attached. Certificates for Payment w re issu and payments received from the Owner, and that current 1. ORIGINAL CONTRACT SUM 221495.00 y p y payment sho er 'n is no due. _1 (buo.U0 2. Net change by Change Orders Ch ce s. Marble The Inc.': 619/2010 3. CONTRACT SUM TO DATE (Line 1 ±2);­111­ By: Date: 4. TOTAL COMPLETED „STORED TO DATE (Column G on G703) 135000.00 State of: 5. RETAINAGE County of: non a. 10 Completed Work 13500.00 Subscribed and sworn to'before (Column D E on G703) me this 9 day, of Q JUNE 2010 b• of Stored Material 0,00 Notary Public: C CQG -gam (Column F on G703) My Commission expires: y? Total Retaina (Lines 5a 5b or Total in Column I of G703) 13500.00 CERTIFICATE FOR PAYMENT 121500.00 In accordance with the Contract Documents, based on on -site observations and the data comprising 6. TOTAL EARNED LESS RETAINAGE this application, the Construction Manager and Architect certify to the Owner that to the best of their (Line 4 Less Line 5 Total) knowledge, information and belief the Work has progressed as indicated, the quality of the Work is in 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT 101700 -00 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 I 19800.00 AMOUNT CERTIFIED 9. BALANCE TO FINISH, INCLUDING RETAINAGE (Attach explanation if amount certified differs from a t! ount Initial all figures on this 82495.00 Application and on t Continuation She hat ar cha ged to conform with the amount certified.) (Line 3 less Line 6) CONST CTIO By: Date: D CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHI Total changes approved in previous months by Owner 0.00 17500.00 By: Date: a Total approved this Month 0.00 0.00 This Certificate s of .aegottable. The AMOUNT CERTIFIED is payable only to the Contractor TOTALS 0.00 17500.00 named herein. ance;'payment and acceptance of payment are without prejudice to any rights of NET CHANGES by Change Order 17500.00 the Owner or omractor under this Contract. CAUTION: You should sign an original AM Contract Document, on which this text appears in RED. An original assures that changes will not be obscured. AIA Document G702/CMaTm 1992. Copyright O 1992 by The American Institute of Architects. All rights reserved. WARNING: This AIA Document is protected by U.S. Copyright Law and international Treaties. 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. 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. TM IR Document G703 1992 Continuation Sheet AIA Document 0702TM, Application and Certification for Payment APPLICATION NO: containing Contractors signed'; certification is attached. CARMEL PERFORMING ARTS APPLICATION DATE: FOUR In tabulations below; amounts are stated to the nearest dollar. 6/9/2010 Use Column 1 on Contracts where variable retainage for line items may apply. P.,E TO: ARCHITECTS PROJECT NO 6/15/2010 A E3 C PRESENTLY D E F G H WORK COMPLETED TOTAL MATERIALS BALANCE SCHEDULED FROM PREVIOUS COMPLETED TO RETAINAGE ITEM DESCRIPTION OF WORK AND STORED NO. VALUE APPLICATION THIS PERIOD STORED TO DATE (G -C) FINISH (]flvnrigble rate) .(D +E) (Not inDorE) (D +E +F) (C G) CERAMIC TILE MOBILIZATION 500.00 500.00 0.00 0.00 500.00 100% 0.00 50.00 BOND T'800.00 1,800.00 0.00 0.00 1,800.00 100% 0.00 180.00 ALLOWANCE 2 20,000.00 10,000.00 0.00 0.00 10,000.00 50% 10,000.00 1,000.00 ALLOWANCE 6 5,000.00 5,000.00 0.00 0.00 5,000:00 100% 0.00 500.00 C.O. 1 (2,500.00) 0.00 0.00 0.00 0.00' 0% (2,500.00) 0.00 C O �2 (15,000.00) (15,000.00) 0.00 0.00 (15,000.00) 100% 0.00 (1,500.00) C O. 3 0.00 0.00 0.00 0;00 0.00 #DiV /0! 4.00 0.00 BASEMENT R.R.S.: LABOR 3,800.00 3,800.00 O.Oo 0.00 3,800.00 100% 0.00 380.00 MATERIAL 5,900.00 5,900.00 0.00 0.00 5,900.00 100% 0.00 590.00 PLENUM RRS LABOR 30,400.00 30,400.00 0.00 0.00 30,400.00 .100% 0.00 3,040.00 MATERIAL 45,600.00 45,600.00 0.00 0.00 45,600.00 100% 0.00 4,560.00 NORTH BOX TIER LABOR 17,600.00 0.00 8,800.00 0.00 8,800.00 50% 8,800.00 880.00 MATERIAL 26,400.00 0.00 13,200.00 0.00 13,200.00 50% 13,200.00 1,320.00 GRAND TOTAL 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. AIA Document G703TM 1992. Copyright 1963, 1965, 1966, 1967, 1970, 1978, 1983 and 1992 by The American Institute of Architects. All rights reserved. WARNING: This Al a Document is protected by U.S. Copyright Law and International Treaties. 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. 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. Document G703 TM -1992 Continuation Sheet AIA Document n'and Certification for Payment APPLICATION NO`. containing Contractor s signed APPLICATION certification is attached. CARMEL PERFORMING ARTS DATE: PG 2 In tabulations below; amounts are stated to the nearest dollar. Use Column I on Contracts where variable retainage for tine items may apply. PERI00 TO: ARCHITECT'S PROJECT NO: A 7SCHEDULED PREVIOUS D E F G H I' WORK COMPLETED TOTAL COMPLETED MATERIALS BALANCE OM PRESEN TLY TO RETAINAGE ITEM DESCRIPTION OF WORK PPLICATION THIS PERIOD STORED AND STORED (G C) FINISH (Ifvariable rate) NO. (D E) (Not in D or E) O DATE (C C) NORTH ORCHESTRA LOW LABOR 10,000.00 10,000.00 0.00 0.00 10,000.00 100% 0.00 1,000.00 MATERIAL 1 5,000.00 15,000.00 0.00 0.00 15,000.00 100 0.00 1,500.00 BALCONY HIGH LABOR 16,000.00 0.00 0.00 0.00 0.00 0% 16,000.00 0.00 MATERIAL 23,495.00 0.00 0.00 0.00 0.00 0% 23,495.00 0.00 TOTAL GRAND TOTAL 203,995.00 113,000.00 22,000.00 0.00 135 0 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. AIA Document G703TI 1992. Copyright 1963, 1965, 1966, 1967, 1970, 1978, 1983 and 1992 by The American Institute of Architects. All rights reserved. WARNING: This AlODocument 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. AIA Document G7021CMa" 1992 Application and Certificate for Payment Constructi �Xanaaer- Adviser Edition TO QWNER: PROJECT: APPLICATION NO: Distribution to: CITY OF CARMFt REDEVELOPMENT COMMISSION 1 CIVIC SQUARE PERIOD TO: FIVE OV`VNE?R GIHNEL, N 46032 CARMEL PEtiF(7F311(ttNG RRTS t?'i15110 CONS {�TE�}II �fiNAl� _1 FROM CONTRACTOR: ViA CONSTRUCTION MANAGER: CONTRACT DATE: CERAMIC TILE ARCHITECT .0:. Chance Bros. Marble Tile, Inc, PROJECT NOS: t 1 CONTRACTOR El M 41 W. h.%icGarty St., VIA AkCHITECT: CSO ARCHETECTS FIELD 0 CONTRACT F bpi napolis, IN 46225 CONTRACTOR'S APPLICATION FOR PAYMENT Tile t nldcrsi;gned Coutrachn cut tiltes thai to thu bust of fhe Uimlractoi kitox'I d i <il� b �liel'the Work covered by this Applicatwn i >r Pavivicnt Its,, been cttlrii?letcd in acco ajm with 11 -C Ap lic ';io is f. lde for Il ti Ine nl W; Si Shown belo in col??l�ecliott with 1;he. Corltuaut" ('(liilf i?l t I)ii .tlllt `rlt). that it :It17f36I11tS hav beer, 7cll L 1 the Cf ?ItI(i'tl IOr 1Qi' Work for which 3i4'Y.ECMS Continua Sheet. f�i I ✓'i)cut lC:1]t �3 i(); iti t]tt Ili'.e (`emit Cates for p. vinel] L�iCI'e t$5 fell and 1711'lll'nts reL'..1VeL front tliCC }5'I ?er, illid ih a t clinc.lit. 221495.00 1:ORIGINL CONTRACT SUM pss °xt]ent's c ii ]e.r -i,l �IOL�: dt 2. Net change by Change Orders CONT E Chan e Bros. marble Tile l,nl �r�,2oia 3. CONTRACT SUM TO DATE (Line I 203995.00 C, ry 4. TOTAL COMPLETED STORED TO DATE „Oc� ?u:nr] c�11 C1703 C1703 184495.00 5€ tt o. 1 diana 8. RE'TAINAGE f'almt} tat: Marlon a 1^ uI C c lnpl icd Wttrt 14199 75 ubscribcd and d nB vo icA)C1t re C 1 u;�t 1 r� +t. Cfr(?a)� 1',// JULY, 2 10 p r a b b of Stotcd 4ta;eriat Public: 0.04 Not:arj (L.t>Iwl1;f f e1l1 tt7 1;1 S' NIN Commissu oa.eApires" 4� ^P '10t111 Rely ao< a e {Ll.l�., 5b or Toval in Column i of G703) 10199 CE RTIFICAT E FOR P7 I 174285.25 In acc rd u;e Willi the. C O11trim I}ciculnei bawd o nn s €ia= bserLat €oils nd�die d tt i ut?1t ]using 8. TOTAL EARN LESS P,ETAINAGE this a1JI5- Ieatmn> tile. C' €?atst Ucli ?n NIana -e r inn Arcliiwct certify to Elie OLL-rier that. to to licsi e]t t}.c:r {L.ice 4 i Ass Li i, 5 1 c,tni) knowie ge. !.n:fortnalion ntld lielit:f the NOTi lsas p og.rosscd as indicated, Lite yti fhi; of tlie'Xork is in 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT S 121 x0:00 accc)ldance with tht Cewuact Doctln]e.Iis. and the Contractor is ell tidcd to pavi tient of the r1N10UN7 CURRENT PAYMEN MEN L emit dc) 279 ?25 AMOUNT REN 'T f�UE... 5Z 9. BALANCE TO FINISH, INCLUDING RETA3I3AGE (r1 tr:7a lr r r;llrrra rrrr?t; i)`ctr t r.crtl cis ifr c? rfit ris c r;1 ,r rr3Frzur r; ta(tcil i,ritictt uc'!,?igiac r r)rr tlr -s 29694.75 djt Cowmim"'On fi7; rrtc ^r ,C'. irrra ed fo con101r11 1vith the arount certrjied') (1 1,c s Li tie 6) CONS UCTION By: gate: J C I-I 1N. C C71 D R SI N1 L1AI 1 ADDITIONS �l)r [7C t::llt)� 5 ARCH CT hh o c.c in pieL to ]s moriths b Owoer 0.00 1'1500 tl0 Dille: 1' I3} i T x111 ]pp t�I� N3e�llih" 0.0 0 p_� This C t'ruaca e i; 1 10 n f1'] ihle- ,I "(1c r 1tC)C I C`1:1�TTF IET is lamlblu on;t' is the C't� ?nii dcxr.ii TOTALS i S) 00 v 17500.00 nalived heromn, kmialice. l aSnl and a)cccplanLC of 13;:Vt it ni are tLilhoiit prC'..1 to any rights trl N_l I C F1 AX I by C b 1_e C)tder 1750) 00 the t kLVl1f.1 Or t._niitrUc for ua] 3e1 this l l t. Director of Redev o ment CAUTION. Y e a r! 1 ,;1. an rricina AIA Contraact 00 0UMer,t, arI which thj text appeev s in ED. An o iqh iat 4 5�iures thae ch ges will not be obScUred. A1A RoCUlnerlt t 702.'Ctr7 1932. Copyright 19 1. v Tile F Ent'rir.,a ii.t;1_ Aichiiecl All rights reserved. WARtilN0: Tfw% Al A` r e¢ vfnOat E r elite 1 t y J.a. Copy iqh Lau✓ 1101 ii =1a: 7. ci s. Un utller i e r �:._..uctiorr or e €iztrtbtaliori of thiN +l A�� l� 7L`:3 Fig "Il 01 ut14' SL3 ET Q( it. tSi'rtY r .uti al fdPkX d.. f >I d't :131G :I'E31t3 i1 l 6 �ltELs, YnL iYell h i'�� JiL °U tt}@ preD, 1.Y Ci g5 G ti: °31 poss11 e ndf'.r the 1i I Ptifo. ic.a v.a aie. "laii ?te"o 101571)iCHl000 len 10 COGie5 0i tilt- �OLUr;;'�rlt Whell cornple'c'it, 10 fq)m1 cvpyFight VlG13Uon s t AIA G,in4art C-Mlit 1 he American lns[Liuze CI', Ali:t'iflec 9 ,P.gai counsel, capyfigr)tCwaiaxin- Y TM AI A Document G703 -1992 Continuation Sheet AIA Document G702TIll Application 'and Certification for Payment, APPLICATION N0: CARMEL PERFORMING ARTS FIVE containing Contactors signed'ceriification is attached. APPLICATION DATE: In tabulations below amounts are stated to the nearest. dollar. 7/7/2010 Use Column 1 on Contracts where variable retainage for line items may apply. PERIOD T0: 7/15/2010 ARCHITECT'S PROJECT NO: A B C D E F G H 1 WORK COMPLETED TOTAL MATERIALS BALANCE SCHEDULED FROM PREVIOUS COMPLETED PRESENTLY TO RETAINAGE ITEM DESCRIPTION OF WORK VALUE APPLICATION THIS PERIOD STORED AND STORED (G C) FINISH (IJ'variable rate) NO. (D c7 (Alot in D or E) (D D A f� (C G) CERAMIC TILE MOBILIZATION 500.00 500.00. 0.00 0.00 500.00 100% 0.00 25.00 BAND 1,800.00 1,800.00 0.00 0,00 1,800.00 100%.7;; 0.00 90.00 ALLOWANCE 2 20,000.00 10,000.00 0.00 0.00 10,000.00 50 10,000.00 500.00 ALLOWANCE 6 5,000.00 5,000.00 0.00 0.00 5,000.00 100% 0.00 250.00 C.O. 1 (z,500.00) 0.00 0.00 0.00 0.00 0% (2,500.00) 0:00 C.O. (15,000.00) (15,000.00) 0.00 0.00 (15, ©00.00) 100% 0.00 (750.00) C.O. 3 0.00 0.00 0.00 0.00:1... 0.00 0 00 0.00 0.00 BASEMENT R.R.S.: LABOR 3,800.00 3,800.00 0.00 0.00 3,800.00 100% 0.00 190.00 MATERIAL 5,900.00 5,900.00 0.00 0.00 5,900.00 100% 0.00 295.00 PLENUM RRS LABOR 30,400.00 30,400.00 0.00 0.00 30,400.00 100% 0.00 1,520.00 MATERIAL 45,600.00 45,600.00 0.00 0.00 45,600.00 100% 0.00 2,280.00 NORTH BOX TIER LABOR 17,600.00 8,800.00 8,800.00 0.00 17,600.00 10^ 0.00 880,00 MATERIAL 26,400.00 13,200.00 13,200.00 0.00 26,400:00 100% 0.00 1,320.00 GRAND TOTAL CAUTION: You should sign an original AIA Contract Document, on which this text appears in RED. An original assures that changes will not be obscur AIA Document G703TM 1992. Copyright 1963, 1965, 1966, 1967, 1970, 1978, 1983 and 1992 by The American Institute of Architects. All rights reserved. WARNING: This AIA Document is protected by U.S. Copyright Law and International Treaties. 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. 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. j �s�.�.r'.= Tnn Document G703 1992 Continuation Sheet AIA Document G702TA', Application °and Certification for Payment, APPLICATION N0 CARMEL PERFORMING ARTS PG 2 containing Contractors sigrledbertification is attached. APPLICATION DATE: In tabulations below; amounts are stated to the nearest dollar. Use Column-1 on Contracts where variable retainage for line items may apply. PERIOD TO: ARCHITECT'S PROJECT NO: A B C D E 1 F G H t WORK COMPLETED TOTAL MATERIALS BALANCE PRESENTLY SCHEDULED FROM PREVIOUS COMPLETED TO RETAINAGE ITEM DESCRLPTION OF WORK VALUE APPLICATION THIS PERIOD STORED AND STORED (G C) FINISH (lfvariablerare) TO No. (D E) (Not in D or E) +DAT) (C G) I NORTH ORCHESTRA LOW LABOR 10,000.00 10,000.00 0.00 0.00 10,000.00 100% 0.00 500.00 MATERIAL 1,5,000.00 15,000.00 0.00 0.00 15,000.00 100% 0.00 750.00 BALCONY HIGH LABOR 16,000.00 0.00 4,000.00 0.00 4,000.00 25% 12,000.00 200.00 MATERIAL 23,495.00 0.00 23,495.00 0.00 23A 100% 0.00 1,174.75 TOTAL GRAND TOTAL 203,995.00 135,000.00 49,495.00 nn 184,495.00 90 °l° 19,500.00 9,224.75 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. AIA Document G703T. 1992. Copyright 1963, 1965, 1966, 1967, 1970, 1978, 1983 and 1992 by The American Institute of Architects. All rights reserved. WARNING: This AIA is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AI0Document, 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. ISA Form a 1 -402 PREPARE IN DUPLICATE Original Contractor 3 Duplicate SubcontracicoSupplier .r AFFIDAVIT AND WAIVER OF LIEN Final 51 Partial Payment to Follow State of Indiana, County of MARION SS WHITNEY J. LONG OFFICE MANAGER AUTHORIZED PERSON being duly sworn states that he Is the of (Name of Officer) (Title) contracted with CITY OF CARMEL REDEVELOPMENT COMMISSION C HANCE BROS. MARBLE &TILE, INC. having to ffurnlsh certain (Subcontractor; Supplier) CERAMICTILE (Contractor) materials and /or labor as follows: CARMEI PERFORMING ARTS (Descropuon) for a project known as WEST LAFAYETTE, INDIANA THE TRUSTEES OF PURDUE UNNERSITY located at and owned by (Owner) and does hereby further state on behalf of the aforementioned subcontractor /supplier: (PARTIAL WAIVER) that there is due from the contractor the sum of SEVE NTY -NIN THOUSAND TWENTY AND NO /100 Dollars IS 79020.00 [x J receipt of which is hereby acknowledged, or J 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 (S J 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 oth, furnished by the undersigned thereto, subject to limitations or conditio s expressed herein, if any• d Erlll es that no other party has any claim or right to a lien on account of any work perfor or ateri turn's d tgned for said project, and within the scope of this affidavit and waiver. CHANCE BROS.MARBLE TILE, INC. R By 1 Firm) (Author ze p e niatnve) 26 2010 WITNESS MY HAND AND NOTARIAL SEAL, this day of `1.• 19 "t (Norar Pub,c 3/2/2016 CONSTANC E F.,CARROLL My Commission Expires Printed: Residing In MARIO County a CQ 1979 INDIANA SUBCONTRACTORS ASSOCIAT1ONr INCORPORATED Unaulhor,=ed rteproduciton Prohibited Rev. 10182 Prescrib tl 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 C�ylv« A r�S r����w �7—, ��r Purchase Order No. Terms `r 22 Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) t 52 79s.2s 72 g5.25 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 eZ �r IN SUM OF 22 5 72� ON ACCOUNT OF APPROPRIATION FOR J TIA 0 Board Members pO r INVOICE NO. ACCT /TITLE AMOUNT I hereby certify that the attached invoice(s), or �0 2 Lf �l��c�d7 l S,�Oo� bill(s) is (are) true and correct and that the 9° 2 S ��60��7 2 S materials or services itemized thereon for which charge is made were ordered and received except 9 2016 ignature �;ro�tsr of Bede -Yelopment Cost distribution ledger classification if Title claim paid motor vehicle highway fund