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167333 12/23/2008 CITY OF CARMEL, INDIANA VENDOR: 362307 Page 1 of 1 1 ONE CIVIC SQUARE GEIGER PETERS INC CHECK AMOUNT: $5,760.00 CARMEL, INDIANA 46032 PO BOX 33807 INDIANAPOLIS IN 46203 CHECK NUMBER: 167333 CHECK DATE: 12/23/2008 DEPARTM ACCOUNT PO NUMBER IN NUMBER AMO UNT DESCRIPTION 902 4460848 01 -08025 5,760.00 4TH GATEWAY /RANGELINE e t .5 Ni l APPLICATION AND CERTIFICATE FOR PAYMENT CONSTRUCTION MANAGER ADVISER EDITION PAGE ONE OF TWO PAGES AIA DOCUMENT G702 /CMa (Instructions on reverse side) TO (OWNER): Carmel Redevelopment Commission PROJECT: Carmel Gateway Arch APPLICATION NO.: 01 -08025 Distribution to: 136th St Rangeline Road PERIOD TO: 10/31/08 OWNER Carmel IN PROJECT NOS: CONSTRUCTION MANAGE] VIA (CONSTRUCTION MANAGER): Keystone Construction ARCHITECHT FROM (CONTRACTOR): Geiger Peters, Inc. 47 S Pennsylvania St 10th Floor CONTRACT DATE: CONTRACTOR P O Box 33807 Indianapolis, IN 46204 Indianapolis, Indiana 46203 C Structural Steel CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge. Infor- Application is made for Payment, as shown below, in connection with the Contract. mation and belief the Work covered by this Application for Payment has been completed Continuation Sheet, AIA Document G703, is attached. 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 pay 1. ORIGINAL CONTRACT SUM 47,500.00 ments received from the Owner, and that current payment shown herein is now due. 2. Net change by Change Orders CO CTO 3. CONTRACT SUM TO DATE (Line I+ 2) 47,500.00 B L l J Date: 10115108 4. TOTAL COMPLETED STORED TO DATE 6,400.00 (Column G on G703) State of: Indiana County of: Marion 5. RETAINAGE: Subscribed and sworn to before a. 10 %of Completed Work methis 15th day of October. 2008 (Column D+E on G703) 640.00 b. 10 ofstored Material te a >a KR.ISTI.NE M. GRACE (Column F on (L ine 5a +Sb or oa NGaar Rubl Si fg f t n' a Total Retainage (Line Sa !7 y C, .fi..illa I Ws. ,z. Total in Column I of G703) 640.00 Notary Public: Kristine M Grace M a ri on CoGOr,' My Commission expires: 6/612013 M;' Commission Expires 6. TOTAL EARNED LESS RETAINAGE 5,760.00 t- JUiiG 06, 2013 (Line 4 less Line 5 Total) ARCHITECT'S CERTIFICATE FOR PAYMENT 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT In accordance with the Contract Documents, based on on -site observations and the data (Line 6 from prior Certificate) comprising this application, the Architect certifies to the Owner that to the best of the Owners knowledge, information and belief the Work has progressed as indicated, the quality of the Work is in accordance with the Contract Documents, and the Contractor 8. CURRENT PAYMENT DUE 5,760.00 is entitled to payment of the AMOUNT CERTIFIED. RECEiglE® 9. BALANCE TO FINISH, INCLUDING RETAINAGE AMOUNT CERTIFIED.. V ENDOR s (Line 3 less Line 6) 41,740.00 (Attach explanation ifamount certified dii fersfrom the amount re4or. lnit0 a4 figures on this Application and on the Continuation Shee! t at are c6 mged46 C. C01'j'j' I_ conform to the amount certified) O C T CONSTRUC ANAGER: O 7 2003 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Total changes approved in B e' p revious months Owner I�1L1AT =R �ABO RONLY Total approved this month S ARCHITECT: APP'D Fsr TOTALS S By: NET CHANGES by Ch- g. Orda So.00 This C e AMOUNT at not ne o table. NT CERTIFIED is p• a e y to to Con- tract erein. Issuance, payment and acceptance of payment are l out pr to any rights of the Owner or Contractor under this Contract. AIA DOCUMENT G7021CMa APPLICATION AND CERTIFICATE FOR PAYMENT' CONSTRUCTION MANAGER- ADVISER EDITION 1992 EDITION' 1992' AIA 1992 THE AMERICAN INSTITUTE OF ARCHITECrs, 1735 NEW YORK AVENUE, N.W., WASHINGTON, G702 /Cma -1992 iA D.C. 2006-5292 Ivy., CONTINUATION SHEET AIA DOCUMENT G703 (Instructions on reverse side) PAGE TWO OF TWO PAGES AIA- Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing APPLICATION NO.: 01 -08025 Contractor's signed Certification is attached. Geiger Peters APPLICATION DATE: 10/15/08 In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 10/31/08 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 SCHEDULED WORK COMPLETED MATERIALS TOTAL BALANCE RETAINAGE VALUE FROM PREVIOU THIS PERIOD PRESENTLY COMPLETED (G:C) TO FINISH ITEM DESCRIPTION OF APPLICATION STORED AND STORED (C -G) NO. WORK ESTIMATED (D +E) (NOT IN TO DATE COST D OR E) (D+E +F) 1 Detailing Shop Drawing 6,400.00 6,400.00 6,400.00 100% 640.00 2 Steel Material Fabrication 23,660.00 0% 23,660.00 3 Miscellaneous Metals 10,540.00 0% 10,540.00 4 Steel Erection 6,900.00 0% 6,900.00 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 47,500.00 6,400.00 6,400.00 13% 41,100.00 640.00 AIA DOCUMENT G702 APPLICATION AND CERTIFICATE FOR PAYMENT 1992 EDITION AIA 1992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVENUE, N.W., WASHINGTON, D.C. 20006 -5292 G703 -1992 Pry WAIVER OF LIEN TO DATE r STATE OF Indiana COUNTY OF Marion SS TO WHOM IT MAY CONCERN: WHEREAS the undersigned has been employed by Keystone Construction to furnish Structural Steel for the premises knows as Carmel Gateway Arch of which Carmel Redevelopment Commission is the owner. THE undersigned, for and in consideration of Five Thousand Seven Hundred Sixty and 00 /100 5,760.00 Dollars, and other good and valuable considerations, the receipt whereof is hereby acknowledged, do(es) hereby waive and release any and all lien or claim of, or right to, lien, under the statutes of the State of Indiana, relating to mechanics' liens, with respect to above described premises, and the improvements thereon, and on the material, fixtures, apparatus or machinery furnished, and on the moneys, funds or other considerations due or to become due from the owner, on account of all labor, services, material, fixtures, apparatus or machinery, furnished to this date by the undersigned, for the above described premises, including extras DATE 10/15/2008 COMPANY NAME Geiger, Peters Inc. ADDRESS P 0 Box 33807 Indianapolis, IN 46203 SIGNATURE AND TITLE Controller EXTRAS INCLUDE BUT ARE NOT LIMITED TO CHANGE ORDERS, BOTH ORAL AND WRITTEN, TO THE CONTRACT. CONTRACTOR S AFFIDAVIT STATE OF Indiana f COUNTY OF Marion J SS TO WHOM IT MAY CONCERN: THE UNDERSIGNED, Debra Burton BEING DULY SWORN, DEPOSES AND SAYS THAT HE OR SHE IS Controller OF Geiger Peters Inc. WHO IS THE CONTRACTOR FURNISHING Structural Steel WORK ON THE BUILDING LOCATED AT 136th St Rangeline Road OWNED BY Carmel Redevelopment Commission That the total amount of the contract including extras* is 47,500.00 on which he or she has received payment of 0.00 prior to this payment. That all waivers are true, correct and genuine and delivered unconditionally and that there is no claim either legal or equitable to defeat the validity of said waivers. That the following are the names and addresses of all parties who have furnished material or labor, or both, for said work and all parties having contracts or sub contracts for specific portions of said work or for material entering into the construction thereof and the amount due or to become due to each, and that the items mentioned include all labor and material required to complete said work according to plans and specifications: NAMES AND ADDRESSES WHAT FOR CONTRACT PRICE AMOUNT THIS INCLUDING EXTRAS- PAID PAYMENT BALANCE DUE Geiger Peters Inc. IStructural Steel 47,500.00 0.00 5,760.00 41,740.00 TOTAL LABOR AND MATERIAL INCLUDING EXTRAS TO COMPLETE 47,500.00 0.001 5,760.001 41,740.00 That there are no other contracts for said work outstanding, and that there is nothing due or to become due to any person for material, labor or other work of any kind done or to be done upon or in connection with said work other than above stated. DATE 10/15/2008 SIGNATURE: SUBSCRIBED AND SWORN TO BEFORE ME THIS 15th DAY OF October 2006. Kristine M Grace Resident of Marion County My Commission expires 6/6/2013 EXTRAS INCLUDE BUT ARE NOT LIMITED TO CHANGE ORDERS, BOTH ORAL AND WRITTEN, TO THE CONTRACT. nr. KR!STINE M. GRACE a Notary Public, State of in INarion County My Corninission Expires Duns 06, 2013 prescribed 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 1 d '?r- /n C Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 10-31 01 090Z 15 /l/. �S 7&0. Total 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. 20 Clerk- Treasurer VOUCHER NO. WARRANT NO. 6C J'a4eC ALLOWED 20 Inc IN SUM OF X15. JrU ��av3 s ,'7D(v.00 ON ACCOUNT OF APPROPRIATION FOR o Board Members PO# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or 1 0Z- 01- 090,, -S LIL W09 5 7 .Ua 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 20 gUr LP r Cost distribution ledger classification if Title claim paid motor vehicle highway fund