HomeMy WebLinkAbout198959 07/06/2011 CITY OF CARMEL, INDIANA VENDOR: 00352259 Page 1 of 1
ONE CIVIC SQUARE CORBITT SONS CONSTRUCTION INC
CARMEL, INDIANA 46032 8728 ROBBINS ROAD CHECK AMOUNT: $15,000.00
«per INDIANAPOLIS IN 46268 -1021 CHECK NUMBER: 198959
CHECK DATE: 7/6/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
660 5023990 3922 -2 15,000.00 OTHER EXPENSES
1A Document 6702 1992
Application and Certificate for Payment
TO OWNER: City of Carmel, Indiana Board of Public PROJECT: ALEXANDIA DR APPLICATION NO: 3922 Distribution to:
Works and Safety PERIOD TO: June 27, 2011 OWNER: X
760 Third Avenue SW
Carmel, IN 46032 CONTRACT FOR: General Construction ARCHITECT:
FROM Corbitt Sons Constructions Company VIA" CONTRACT DATE: CONTRACTOR:
CONTRACTOR: Inc. ARCHITECT: PROJECT NOS: S 12054 FIELD:
8728 Robbins Road
Indianapolis, IN 46268 OTHER:
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 with the
Application is made for payment, as shown below, in connection with the Contract. 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 were issued and payments received from the Owner, and that current
1. ORIGINAL CONTRACT SUM 60,000.00 Payment shown I rein is now due.
2. NET CHANGE BY CHANGE ORDERS 0.00 CONTRA T JR:
3. CONTRACT SUM TO DATE (Line I± 2) y t
60,000.00 B v1 Date: June 27, 2011
4. TOTAL COMPLETED STORED TO DATE (Column G on G703) 60,000.00 State of: Indiana
5. RETAINAGE: County of: Marion
a. 0 of Completed Work Subscribed and sworn to before
(Column D E on G703) 0.00 me this A day of
o
b. 0 of Stored Material
(Column F on G703) 0.00 Notary Public: Keesha Sneed le¢,:9k/t��
Total Retainage (Lines 5a 5b or Total in Column I of G703) 0.00 My Co m m i ss ion expires: August 14, 2014
6. TOTAL EARNED LESS RETAINAGE 60.000.00 ARCHITECT'S CERTIFICATE FOR PAYMENT
(Line 4 Less Line 5 Total) In accordance with the Contract Documents, based on on -site observations and the data comprising
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT 45,000.00 this application, the Architect certifies to the Owner that to the best of the Architect's knowledge,
Line 6 from nor Certificate Information and beliefthe Work has progressed as indicated, the quality ofthe Work is in accordance
P with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT
8. CURRENT PAYMENT DUE I 15,000.oq CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE AMOUNT CERTIFIED 15,000.00
(Line 3 less Line 6) 0.00 (Attach explanation if amount certified diers from the amount applied. Initial all figures on this
Application and on the Continuation Sheet that are changed to conform with the amount certified.)
C HANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHITECT:
T otal changes approved in previous months by Owner 0.0 0.0 By: Date:
T otal approved this Month 0.0 0.0
TOTALS 0.0 0.0 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
T CHANGES by Change Order 0.0 the Owner or Contractor under this Contract.
AIA Document G702TM —1992. Copyright 1953, 1963, 1965, 1971, 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. This document was produced byAIA software at 10:42:02 on 06127/2011 under Order No.5792802235 1 which expires on 12/13/2011, and is not for resale.
User Notes: (1484409941)
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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
352259
CORBITT SONS CONSTRUCTION, INC. Purchase Order No.
P.O. Box 66975 Terms
Indianpolis, IN 46266 Due Date 6/28/2011
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
6/28/2011 3922 -2 $15,000.00
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 Ile,
Date 0 1CIW
VOUCHER 115379 WARRANT ALLOWED
352259 IN SUM OF
CORBITT SONS CONSTRUCTION, II`
3 bpb��
Indianpolis, IN 4626� z -(OZ(
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
3922 -2 D $15,000.00
i
i
I
Voucher Total $15,000.00
Cost distribution ledger classification if
claim paid under vehicle highway fund