158945 04/30/2008 CITY OF CARMEL, INDIANA VENDOR: 148000 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF TRANSPORTATION
CHEGK AMOUNT: $7,DOD.00
CARMEL, INDIANA 46032 100 N SENATE AVE, RM N725
ATTN: CASHIER CHECK NUMBER: 158945
INDIANAPOLIS IN 45204
r� CHECK DATE: 4/30/2008
DEPART9(ENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
202 4462630 7,000.00 116TH ST COLLEGE TO R
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INDIANA DEPARTMENT OF TRANSPORTATION INVOICE
100 NORTH SENATE AVENUE, ROOM N725
INDIANAPOLIS, INDIANA 46204 -221.6
2 R
Customer No: CST000001811
Bill To: Invoice: 000001897
Invoice Date: 4/1412008
Carmel Invoice Type: LPA
Dept. Of Engineering
One Civic Square
Carmel IN 46032 AMOUNT DUE: $7,000.00
Payment is Due Upon Receipt of Invoice
PLEASE RETURN TOP PORTION WITH YOUR PAYMENT, ATTN: CASHIER
Line Description Quantity Unit Amt Net Amount
1 Contract #R -27495 1.00 7,000.00 7,000.00
Project #B886010, Contract #R- 27495, Road rehabilitation for 116th St
from Ran Rd to Colle Ave, chan order #32 (see attached)
Subtotal: 7,000.00
AMOUNT DUE: $7,000.00
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For billing questions, please call: 317- 232 -5384 Invoice: 000001897
Indiana Department of Transportation, 100 North Senate Avenue, Indianapolis, Indiana 46204 -2216
y 1 P_�a Co
r ha Orde Order Date Required Date Page
r IIND�T Or er 08809109 04/02/2008 04/12/2008 1 of 1
Indiana Department o Truction ransportation
Smle Form 4W 9(Ra16 -07) Fund /Object/Center: 40001564400 1108160
e�.z. Approved by Slat. BoardofAcc M., -2007 Requisition Number: 0000009385
Approved by Auditor of Slam, .2007 Federal ID: 1 351128289
Vendor 0000087540 000001 1 Agency: 00800 Indiana Dent of Transportation
BEAN CONSTRUCTION INC Ship To Dept Of Transportation
Remit to 5292 W CR 100 N Construction Management Divisi
BOGGSTOWN IN 46110 100 N SENATE AVE RM N855
INDIANAPOLIS IN 46204
BEATY CONSTRUCTION INC Bill To Indiana Dept of Transportation
Vendor 5292 W CR 100 N Dept Of Transportation
Name BOGGSTOWN IN 46110 Accounting
Address 100 N SENATE AVE RM N725
INDIANAPOLIS IN 46204
Vendor Name: Buyer Name: Sweeney, Cheryf-800
Contact email: eMaik CSWEENEY @indot.IN.gov
Phone:
20% LPA 80% FEDERAL. change order 32 PE Eric Von Hoven orig po 08804092
A0 40
ltertl.No -u Descrl tlon F.OB,Diis"tlna tton x Qt 'Ordered Qt Recd.G aUOvl `#4�4Jh[t OA( E9cten�edaQmt
1- 1 R 27495 -A BIKEIPEDESTRIAN TUNNEL 1.0000 0 EA 35,000.0000 35,000.00
GREENFIELD DISTRICT PCN:0401387
6886010 NEW BRIDGE CONCRETE u�' 4
CONSTRUCTION HAMILITON COUNTY ON Ppf SGyS/ctp
THE MONON RAIL_ TRAIL AT 116TH
STREET IN CARMEL i:�✓L /O� ✓(o
Deliveries acceptable only between 8:00 AM and 3:00 PM, Monday through Friday, excluding State QSl�T
Holidays
y 4 40
I z €.t k x nits,ofcAAeasure ElandltnA.;Tofals Signatures w'� ''ID F A WU
U` z,
The following UN /CEFACT Unit of Measure Date Invoice Received: (Month /Da (Year)
Common Codes are used in this document: Goods /Services Received Date: (Month /DayNear)
EA Each Internal Contract Terms and Conditions Satisfied: (Month /DayNear)
Exemptantergovernmental (Pursuant to IC 5- 17 -5 -2)
Good Faith Dispute (Dispute Pursuant to IC 4- 13 -2 -20 81 IC 5- 11 -10 -2)
Total PO Amt. 35,000.00
Issued by the the Indiana Department of Transportation FUNDING ENCUMBERED BY THE AUDITOR OF STATE
I certify that there is sufriclant unencumbered balance In the above
account to cover the amount of this order, and that funds have been set
aside for payment thereof.
Authorized signature, Auditor of State
9 /J� J j r •c b Bate Signed(Month0aylYear)
.,C ✓vQ J i J i F h 1! 5
J A LAS k
Tcontract CONFIRMATION OF RECEIPT APPROVAL FOR PAYMENT
certify that the items listed above were received. Ail commodities tify that the vendor has performed in accordance with the terms and
ppeared to conform to specifications and showed no patent J a obligations pertaining to this Purchase Order, and hereby
siesta sxce t es otherwise noted. e e a a a orize and approve payment of the claims.
Signature of Receiver 'J J D1te 9gn9d(MontftfD jN(far) s orized Signature for Agency
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Illlll VIII VIII VIII VIII IIII 1 lllfl IIII I'll! ��ill IIII� III�1 ��I I �EII� I�IfI h�l� �I� I I� II I Sst copy (Vendor) 2nd eepy(Agencyi 3rd copy(Audlmrl
00800 0008809109 4th copy tD1vlri.nlD,.Ir1c1)
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
T CITY OF CARMEL
An invoice or -:bill to:be properly itemized must show: kind of service, where performed, dates service rendered, by
t t 1 r l� f i O r t pshhour, number of units, price per unit, etc.
ATTN: Cashier Payee
n N726 Purchase Order No.
Me r Rom
ntlion�nnli�• 1A1 ri4 2rf4G Terms
1 hdia„apel s, -4�
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
cmoW'897 roje Contract #R -27495 $7,000.00
1 16th St reet, Range Line to College Change Order #32
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
VOUC',HER NO. WARRANT NO.
Indiavea ppP@Mp ant of Trancnnrtatinn
ALLOWED 20
ATT- C2hIeP IN SUM OF
100 N. Senate Avenue, Room N725
Indianapolis, IN 46204 -2216
$7,000.00
ON ACCOUNT OF APPROPRIATION FOR
Department of Engineering
Board Members
PO# or INVOICE NO. ACCT /TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
Na 000001897 202 4462838 7,000.00 bills) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
2 2lIJ
20
Signature
Grr /9L2 �w,c)����P
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund