158432 04/15/2008 CITY OF CARMEL, INDIANA VENDOR: 359476 Page l of 1
0 ONE CIVIC SQUARE HASSER CONSTRUCTION CO INC CHECK AMOUNT: $6,699.00
CARMEL, INDIANA 46032 2201 E 54TH ST
INDIANAPOLIS IN 46220 CHECK NUMBER: 158432
CHECK DATE: 411512008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
106 5023990 6 6,699.00 OTHER EXPENSES
APPLICATION AND CERTIFICATE FOR PAYMENT Similar to AIA DOCUMENT G702 PAGE ONE OF ONE PAGES 1
TO OWNER: Carmel /Clay Dep. Of Parks and Recreation PROJECT: West Park Restroom Bl.d. Impr_ovements. APPLICATION NO.: 6
Mark Westermeier, Director APPLICATION DATE: 10/3/07
1411 E. 116th Street r PERIOD TO: 10/3/07
Carmel, IN 46032 APR 2 2008 PROJECT NOS.: HCC 2703
FROM CONTRACTOR: HaSSer Construction CO., Inc. ARCHITECT: Schmidt Associates, T `J^� ^NYC Project# 2006 -032
C
2201 East 54th Street 320 East Vermont Street CONTRACT DATE: 1/23/07
Indianapolis, Indiana 46220 Indianapolis, IN 46204
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and belief the
Application is made for payment, as shown below, in connection with the Contract. Work covered by this Application for Payment has been completed in accordance with the Contract Documents,
Continuation Sheet, AIA Document G703, is attached. that all amounts have been paid by the Contractor for Work for which previous Certificates for Paynment were
issued and payments received from the Owner, and that current payment shown herein is now due.
1. ORIGINAL CONTRACT SUM 55 ,499
2. Net change by Change Orders CONTRACTOR:
3. CONTRACT SUM TO DATE (line 1 +2) 55 ,499 By: Jack White Project Manager Date: 10/3/2007
4. TOTAL COMPLETED STORED TO DATE 55 ,499 State of: diana
(column G on G703) County of: Marion tt��
6. RETAINAGE: Subscribed and sworn to before me this 3 day of 7 oCQ�
a. of Completed Work
(columns E on G703)
b. of Stored Material L-7
(column F on G703) Notary Public:
Total Retainage (line 5a +5b or column I of G703) My Commission expires: met�Iate
6. TOTAL EARNED LESS RETAINAGE 55 ,499
(line 4 less line 5 total) ARCHITECT'S CERTIFICATE FOR PAYMENT
In accordance with the Contract Documents, based on on -site observations and the data comprising this
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT 48,800 application, the Architect certifies to the Owner that to the best of the Architect's knowledge, information and belief
(line 6 from prior certificate) the Work has progressed as indicated, the quality of the Work is in accordance with the Contract Documents, and
the Contractor is entitled to payment of the Amount Certified.
8. CURRENT PAYMENT DUE 6 ,699
9. BALANCE TO FINISH, INCLUDING RETAINAGE AMOUNT CERTIFIED
(line 3 less line 6) (Attach explanation if amount certified differs from the amount applied for. Initial all figures on this Application and
on the Continuation Sheet that are changed to conform to the amount certified.)
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHITECT:
Total changes approved in previous
months by Owner +1 -1 By: Date: D °jl7i�,�08
Total approved this month 0 0 This Certificate is n negotiable. The Amount Certified is payable only to the Contractor named herein. Issuance,
Totals 1 -1 payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this
NET CHANGES by Change Order 0 Contract.
lot q 7
16 (e 7
CONTINUATION SHEET Schedule values Similar to AIA DOCUMENT G703 PAGES 1
APPLICATION NO. 6
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing Contractor's signed APPLICATION DATE: 10/03/07
Certification, is attached. In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 10/3/07
PROJECT NAME: Carmel Restroom Improvements
CONTRACTOR: Hasser Construction Co. Inc.
A B C D E F G H I
WORK COMPLETED RETAINAGE
FROM MATERIALS TOTAL
PREVIOUS PRESENTLY COMPLETED
SCHEDULED APPLICATION (D STORED (NOT IN AND STORED TO BALANCE TO
ITEM DESCRIPTION OF WORK VALUE E) THIS PERIOD D OR E) DATE (D E F) (G C) FINISH (C G) 10%
1 General Conditions Bond 13,999 12,850 1,149 13,999 100% 0 1,400
2 Select Demo 2,000 2,000 0 2,000 100% 0 200
3 Rough /Finish Carpentry 5,000 5,000 0 5,000 100% 0 500
4 Insulation/ Sealant and Caulk 2,000 2,000 0 2,000 100% 0 200
5 Windows and Window Flashing 5,000 5,000 0 5,000 100% 0 500
6 Finishes /Painting 1,500 1,500 0 1,500 100% 0 150
7 Mechanical 20,000 20,000 0 20,000 100% 0 2,000
8 Electrical 6,000 6,000 0 6,000 100% 0 600
9 0 0 #DIV /0': 0 0
1 0 0 #DIV /0! 0 0
11 0 0 #DIV /0! 0 0
12 0 0 #DIV /0! 0 0
13 0 0 #DIV /0! 0 0
14 0 0 #DIV /0! 0 0
15 0 0 #DIV /0! 0 0
0 0 #DIV /0! 0 0
0 0 #DIV /0! 0 0
0 0 #DIV /0! 0 0
0 0 #DIV /0! 0 0
0 0 #DIV /0! 0 0
TOTAL 55,499 54,350 1,149 0 55,499 100% 0 5,550
1 OF 1
AFFIDAVIT AND WAIVER OF LIEN
E l FINAL PARTIAL R PAYMENT TO FOLLOW
STATE OF INDIANA
COUNTY OF MARION, SS:
Jack White being duly sworn states that he is the Project Manager
of Hasser Construction Co. Inc. having contracted with Carmel /Clay Dep. Of Parks and Recreation
to furnish certain materials and /or labor as follows: General Construction for a project known as
West Park Restroom Bld. Improvem( located at 2700 W. 116th Street, Carmel IN and owned by
Carmel /Clay Dep. Of Parks and Reci and does further state:
PARTIAL WAIVER: that the balance due from the Owner is the sum of
Dollars)
receipt of which is hereby acknowledged; or
the payment of which has been promised as the sole consideration for this Affidavit and
Partial Waiver of Lien which is given to and for said amount, effective upon receipt of
such payment;
FINAL WAIVER: that the FINAL balance due from the Owner is the sum of
Six Thousand Six Hundred Ninety Nine Dollars) $6,699
R receipt of which is hereby acknowledged; or
X 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 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.
Hasser Construction Co., Inc.
Company Name
a1z'
u&rized Representative
Project Manager
Title
WITNESS MY HAND AND NOTARIAL SEAL, this -3 day of c7 Z D
My Commission expires: A.�S✓ I� EiU
Notary Public
County of Residence: c0,.L/
Printed
c
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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
Purchase Order No.
Hasser Construction Terms
2201 E. 54th St.
Indianapolis, IN
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
3121108 6 West Park Restrooms App #6 6,699.00
Total 6,699.00
1 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.
Hasser Construction Allowed 20
2201 E. 54th St.
Indianapolis, IN 46220
In Sum of
6,699.00
ON ACCOUNT OF APPROPRIATION FOR
106 Park Impact Fee Fund
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
106 6 5023990 6,699.00 1 hereby certify that the attached invoice(s), or
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
14 -Apr 2008
ignatur
6,699.00 Business Services Manager
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund