159850 05/28/2008 CITY OF CARMEL, INDIANA VENDOR: 356511 Page 1 of 1
ONE CIVIC SQUARE DAWSON INC
CARMEL, INDIANA 46032 6221 S HARDING ST CHECK AMOUNT: $14,702.70
INDIANAPOLIS IN 46217 CHECK NUMBER: 159850
CHECK DATE: 5/28/2008
DEPA RTMENT ACCOU PO NUMBER INVOICE NUMBER AM OUNT DESCRIPTION
902 4460805 APPL 0005 14,702.70 RETAIL SITE #5
APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT G702 PAGEONEOF PAGES
TO OWNER: Carmel Redevelopment Commission Distribution to:
P PROJECT: CARMEL PARCEL #5 SITE A PPLICATION NO: 0005
One Civic Square
Carmel, IN 46032 PERIOD TO: 3/31/2008 OWNER
Contractor's Project No. 250007 PROJECT NOS.: ARCHITECT
FROM CONTRACTOR: Dawson Incorporated ARCHITECT: CSO Architects El CONTRACTOR
El 6221 S. Harding Street 280 E. 96th Street
Indianapolis, IN 46217 Indianapolis, IN 46280 CONTRACT DATE: 6/23/2005
CONTRACT FOR:
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 completed in accordance
Application is made for payment, as shown below, in connection with the contract. with the Contract Documents, that all amounts have been paid by the Contractor
Continuation Sheet, AIA Document G703, is attached. for Work for which previous Certificates for Payment were issued and payment received
1. ORIGINAL CONTRACT SUM $392.700.00 from the Owner, and that current payment shown herein is now due.
CONTRA RRawson crated
2. Net change by Change Orders $34.268.00 B �S!Cel1� Date:
4/25/2008
Y
3. CONTRACT SUM TO DATE (Line 1 ±2) $426,968.00
4. TOTAL COMPLETED STORED TO DATE $294,054.00 State of INDIANA
(Column G on G703) County of: MARION
5. RETAINAGE: Subscribed and sworn to before
a. 5.000 of Completed Work $14,702.70 me this 4/25/2008
(Columns D E on G703)
b. 0 of Stored Material $0.00 Notary Public:
Columns F on G703) My Commission ekpires: 8/ /2 14
Total al R
Columns oil G7 b or $14,7 02.70
ARCHITECT'S CERTIFICATE FOR PAYMENT
Total in Columns 1 on G703)
6. TOTAL EARNED LESS RETAINAGE $279,351.30 In accordance with the Contract Documents, based on on -site observations and the data
(Line 4 less Line 5 Total) comprising this application, the Architect certifies to the Owner that to the best of the
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT Architect's knowledge, information and belief the Work has progressed as indicated, the
Line 6 from prior Certificate ....I $264 ,648.60 quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE is entitled to payment of the AMOUNT CERTIFIED.
14 702.70
9. BALANCE TO FINISH, INCLUDING RETAINAGE AMOUNT CERTIFIED I S 14,702.770
(Line 3 less Line 6) $147,616.70 (Attach explanation if amount certified differs from the amount applied for. Initial
all figures o is Application and on the Continuation Sheet that are changed to
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS conforr o t e am f t cert' ied.)
Total changes approved in AR IT T
p revious months by Owner $34,268.00 $0.00 B Date: 0 O$
Total approved this Month $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
TOTALS $34,268.00 $0.00 Contractor named herein. Issuance, payment and acceptance of payment are without
NET CHANGES b Change Orderl $34,268.00 prejudice to any rights of the Owner or Contractor under this Contract.
AIA DOCUMENT G702 APPLICATION AND CERTIFICATE FOR PAYMENT. 1992 EDITION AIA00. (911992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK
``I I AVENUE. N.W., WASHINGTON. D.C. 20006 -5292 WARNING: Unlicensed photocopying g violates U.S. co G702 1992
p py b copyright laws and will subject the violator to legal prosecution.
"This document has been reproduced electronically with the permission o ft h American Institute of Architects under License 97003 to Primavera Systems, Inc. Reproduction of this document without project- specific information is not permitted.
Contact The American Institutee•(Architecrs t =verify the current version of thi s document and license status."
CONTINUATION SHEET AIA DOCUMENT G703 PAGE I OF I PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 0005
containing Contractor's signed Certification, is attached. APPLICATION DATE:
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 3/31/2008
Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO.:
A B C D E F G H I
WORK COMPLETED MATERIALS TOTAL BALANCE
ITEM PRESENTLY COMPLETED RETAI AGE
DESCRIPTION OF WORK SCHEDULED FROM PREV[OUS TO
STORED AND STORED TO FINISH
NO. VALUE IF VARIABLE)
APPLICATION THIS PERIOD (NOT IN D OR E) RATE
DATE (D +E +F) (G -C) (C G)
000000001 SANITARY SEWER
000000002 Labor $66,256.00 $10,600.96 $0.00 $0.00 $10,600.96 16.000 $55,655.04
000000003 Material $95,344.00 $22,882.56 $0.00 $0.00 $22,882.56 24.000 $72,461.44
000000005 MONON TRAIL
000000006 Asphalt $23,000.00 $23,000.00 $0.00 $0.00 $23,000.00 100.000 $0.00
000000007 Labor $27,400.00 $27,400.00 $0.00 $0.00 $27,400.00 100.000 $0.00
000000008 Material $29,900.00 $29,900.00 $0.00 $0.00 $29,900.00 100.000 $0.00
000000010 EXISTING DITCH
000000011 Labor $3,900.00 $3,900.00 $0.00 $0.00 $3,900.00 100.000 $0.00
000000012 Material $6,900.00 $6,900.00 $0.00 $0.00 $6,900.00 100.000 $0.00
000000014 STORM SEWER
000000015 Labor $51,800.00 $51,800.00 $0.00 $0.00 $51,800.00 100.000 $0.00
000000016 Material $88,200.00 $88,200.00 $0.00 $0.00 $88,200.00 100.000 $0.00
10 000000019 1 Change Order No. 1 $34,268.00 II $29,470.48 $0.00 $0.00 I $29,470.48 86.000 $4,797.52
1 TOTAL 1 $426,968.001 $294,054.001 $0.001 $0.0 $294,054.0 68.87 %1 $132,914.0
AIA DOCUMENT G703• APPLICATION AND CERTIFICATE FOR PAYMENT 1992 EDITION AIA69 t01992 THE AMERICAN INSTITUTE OF ARCI IrrECrS, 1735 NEW YORK G703 -1992
l
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.
'This document has been reproduced electronically with the permission of The American Institute of Architects under License 97003 to Primavera Systems, Inc. Reproduction of this document without propndifiic information is not permitted. Contact The American Institute of Architects
to verifv the current version of this docume it and license' Satus."
PARTIAL WAVIER OF LIEN
STATE OF INDIANA
SS:
COUNTY OF MARION
KNOW ALL MEN BY THESE PRESENTS, That the undersigned:
Dawson Incorporated
for and in consideration of:APPLICATION NO: 0005 PERIOD TO: 3/31/2008
for payment in the amount of. $14,702.70
does upon receipt of said payment hereby waive, release and surrender any and all liens or claims or rights to
lien, for labor, material and /or services, 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 situated in the
County of Marion, State of Indiana, described as follows:
PROJECT: CARMEL PARCEL #5 SITE
PROJECT NO:
ARCHITECT: CSO Architects
CONTRACT:
Dawson Incorporated
CONTRACTOR
Date: 4/25/2008
By:
State of INDIANA
County of: MARION
Subscribed and sworn to before me on: 4/25/2008
Notary Public: M
My Commission expires: 8/28/2014
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.
Payee
D a wfon ��ce�pe... Purchase Order No.
Z 1 Terms
I., 44717 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
4 /M /0 #P L -0005' N' -ee If SB 1q 70 Z. 70
r�
Total 70
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in'acc rdance
with IC 5- 11- 10 -1.6.
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
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IN SUM OF
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ON ACCOUNT OF APPROPRIATION FOR
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Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
aZ RPPL oca-T yw60865 1 ti ?oz, 7o 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
0 v�
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Cost distribution ledger classification if
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claim paid motor vehicle highway fund