162857 08/20/2008 CITY OF CARMEL, INDIANA VENDOR: 00351429 Page 1 of 1
is 0 ONE CIVIC SQUARE M.K. BETTS ENGINEERING INC CHECK AMOUNT: $7,500.00
CARMEL, INDIANA 46032 PO BOX 2533
•w,_ ANDERSON IN 46018 CHECK NUMBER: 162857
CHECK DATE: 8/20/2008
D EPARTM E NT AC COUNT PO NUMBER I NUMBER AMOUNT DESCRIP
659 5023990 22 7,500.00 OTHER EXPENSES
F
c".)
APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT G702 (instructions on reverse side) P�Gl, ONE OF PACES
TO (OWNER): City of Carmel PROJECT: Gravity Belt Thickener Facility APPLICATION NO: Twenty–Twd:)istTlbution to:
One Civic Square Contract 56 Final RetainagE✓ OWNER
Carmel, IN 46032 Carmel, IN PERIOD TO: 06-30-08 El ARCHITECT
E CONTRACTOR
FROM (CONTRACTOR): VIA (ARCHITECT): ARCHITECT'S
Jones Henry Engineers, Ltd.
M. K. Betts Engineering PROJECT NO:
Contracting, Inc.
CONTRACT FOR:. Invoice No. 05 -354.22 Final Ret. CONTRACT DATE:
Application is made for Payment, as shown below, in connection with the Contract.
CONTRACTOR "S APPLICATION FOR PAYMENT Continuation Sheet, AIA Document C703
is attached.
CHANCE ORDER SUMMARY 1. ORIGINAL CONTRACT SUM S 874 000.00
18711.25
previous months Change Orders approved in ADDITIONS DEDUCTIONS 2 Net change by Change Orders I.
by Owner 3. CONTRACT SUM TO DATE (Line 1 2) S 892,711.25
TOTAL 4. TOTAL COMPLETED STORED TO DATE S 838,691.25
(Column G on G703)
Approved this Month
Number Date Approved 5. RETAINAGE:
CO#1 –0– $15789275 a. of Completed Work 5
(Column D E on G703)
CO#2 4,829.00 –0– b. of Stored Material
CO#3 $171,775.00 –0– (Column F on G703)
Total Retainage (Line 5a 5b or
TOTALS $176 604.00 157, 892.75 Total in Column I of G703) S
–0– I 2
6. TOTAL EARNED LESS RETAINAGE 838,691.25
Net change by Change Orders $'18,711.25
The undersigned Contractor certifies that to the best of the Contractor's knowledge, (Line 4 less Line 5 Total)
information and belief the Work covered by this Application for Payment has been 7. LESS PREVIOUS CERTIFICATES FOR
completed in accordance with the Contract Documents, that all amounts have been PAYMENT (Line 6 from prior Certificate) 831 191 .25
paid by the Contractor for Work for which previous Certificates for Payment were
8. CURRENT PAYMENT .DUE 7,500.00
issued and payments received from the Owner, and that current payment shown 54,020.00
9. BALANCE TO FINISH, PLUS RETAINAGE
herein is now due.
(Line 3 less Line 6)
CONTRACTOR: M. K. Betts Engineering Contracting, Inc.. State of: Indiana County of: Madison
Subscribed and sworn to before me this 30th day of June 2008
Notary Public
Bv: June 30, 2008
Date: My Commission expires: October 28 2015
AMOUNT CERTIFIED S
ARCHITECT'S CERTIFICATE FOR PAYMENT
(Attach explanation if amount certified differs from the amount applied for.)
In accordance with the Contract Documents, based on on-site observations and the ARCHITECT:
data comprising the above application, the Architect certifies to the Owner that to the
best of the Architect's knowledge, information and belief the Work has progressed as By: Date: 6P
indicated, the quality of the Work is in accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT CERTIFIED. fi t. is no negotiable.
This Certificate is no negotiable. The AMOUNT CERTIFIED is pavab!e only to the
Contractor named herein. Issuance, payment and acceptance of payment are without
prejudice to any rights of the Owner or Contractor under this Contract.
AIA 00rU"fh'T r,70' 7n1 lr jr) rftTiV1r\TF
ti.
CONTINUATION SHEET AIA DOCUMENT 0703 Gravity Belt Thickener Facility PAGE 1 OF 2 PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing APPLICATION NUMBER: Twenty -Two (22)
Contractor's signed Certification is attached. APPLICATION DATE:
g June 30, 2008
In tabulations below, amounts are stated to the nearest dollar. PERIOD FROM: Start
Use Column I on Contracts where variable retainage for line items may apply. TO: Finish
ARCHITECT'S PROJECT NO: N
o-`
A B C D E F G H I-
5'
WORK COMPLETED TOTAL COMPLETED'
ITEM DESCRIPTION OF WORK SCHEDULED ,o BALANCE RETAINAGE
VALUE This Application AND STORED TO FINISH
Previous Stored Materials TO DATE (G- (C —G)
Applications Work in Place (not in D or E) (D +E +F) K'
r
1. Mobilization, Bond
Insurance 20,000.00 20,000.00 -0- -0- 20,000.00 100 -0-
2. Demolition 5,500.00 5,500.00 -0- -0- 5,500.00 100 -0-
3. Concrete 7,000.00 7,000.00 -0- -0- 7,000.00 100 -0
4. Carpentry 6,000.00 6,000.00 -0- -0- 6,000.00 100 -0-
i +i
5. Yard Piping 25,000.00 25,000.00 -0- -0- 25,000.00 100 -0-
6. Plant Piping 46,000.00 46,000.00 -0- -0- 46,000.00 100 -0- y,
7. Valves 21,000.00 21,000.00 -0- -0- 21,000.00 100 -0-
8. Miscellaneous Metals 22,500.00 22,500.00 -0- -0- 22,500.00 100 -0-
9. Gravity Belt Thickener 163,500.00 163,500.00 -0- -0- 163,500.00 100 -0-
10. Polymer Solution Equip. 40,000.00 40,000.00 -0- -0- 40,000.00 100 -0-
11. Sludge Grinder 56,500.00 56,500.00 -0- -0- 56,500.00 100 -0- 's
12. Thickened Sludge Pump 56,500.00 56,500.00 -0- -0- 56,500.00 100 -0-
13. Thickener Feed Pump 68,500.00 68,500.00 -0- -0- 68,500.00 100 -0-
14. Flow Meters 7,100.00 7,100.00 -0- -0- 7,100.00 100 -0-
15. Water Filters 17,000.00 17,000.00 -0- -0- 17,000.00 100 -0- r:
16. Software Development 101000.00 -0- -0- -0- -0- 00 10,000.00;.
17. Sump Pump Modifications 6,000.00 -0- -0- -0- -0- 00 6
18. Doors 15,000.00 1,980.00 -0- -0- 1 13 13,020.00
4:
19. jMonorail 10,000.00 -0- -0- -0- -0- 00 10,000.00:
r
4'
AIA DOCUMENT G703 CONTINUATION SHEET APRIL 1978 EDITION AIA'b ro 1978
THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK, AVE., N.W.. WASHINGTON. D.C. 20006 0703 1978
CONTINUATION SHEET AIA DOCUMENT 0703 Gravity Belt Thickener Facility PAGE 2 OF 2 PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing APPLICATION NUMBER: Twenty -Two ("22
Contractor's signed Certification is attached. APPLICATION DATE: June 30, 2008
In tabulations below, amounts are stated to the nearest dollar. PERIOD FROM: Start
Use Column I on Contracts where variable retainage for line items may apply. TO: Finish
ARCHITECT'S PROJECT NO:
A B C D E F G H I
ITEM DESCRIPTION OF WORK SCHEDULED WORK COMPLETED TOTAL COMPLETED
Application AND STORED BALANCE RETAINAGE
This A
o. VALUE PP TO FINISH
Previous Stored Materials TO DATE (G =C) (C —G)
Applications Work in Place (D +E +F)
(not in D or E)
20. Odor Control Curtain 15,000.00
21. Masonry 5,100.00 5,100.00 -0- -0- 5,100.00 100 -0-
22. Painting 15,600.00 15,600.00 -0- -0- 15,600.00 100 -0-
23. HVAC 153,000.00 153,000.00 -0- -0- 153,000.00 100 -0-
24. Electrical 73,200.00 73,200.00 -0- -0- 73,200.00 100 -0-
25. Pipe Insulation 2,700.00 2,700.00 -0- -0- 2,700.00 100 -0-
26. Asphalt Paving 6,300.00 6,300.00 -0- -0- 6,300.00 100 -0-
CO #1 Change Order No.1
1. Equip. Changes, Etc. 176,000.00 176,000.00 -0- -0- 176,000.00 100 -0-
2. Deduct Lighting 5,500.00 5,500.00 -0- -0- 5,500.00 100 -0-
3. Remove High Spots in
Floor 242.25 242.25 -0- -0- 242.25 100 -0-
4. PVC Conduit 4,900.00 4,900.00 -0- -0- 4,900.00 100 -0-
5. Deduct Fiber Optic
Wiring 916.00 916.00 -0- -0- 916.00 100 -0-
6. Change Vent Line -0- -0- -0- -0- -0- 100 -0-
7. Revise GBT Platform 4,070.00 4,070.00 -0- -0- 4,070.00 100 -0-
8. Plant Water Piping
Valves 3,610.00 3,610.00 -0- -0- 3,610.00 100 -0-
9. GBT Control Panel 575.00 575.00 -0- -0- 575.00 100 -0-
i
AIA DOCUMENT G703 CONTINUATION SHEET APRIL 1978 EDITION AIA's CU 1978
i
THE Ay.= RICP.N INST17UTE OF \RC'-1 1735 NEW YORE: AVE %V WA.SHINc;-O,.
I
CONTINUATION SHEET AIA DOCUMENT 0703 P AGE OF PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing APPLICATION NUMBER: Twenty —Two (22) F
Contractor's signed Certification is attached. APPLICATION DATE: June 30,"2008
In tabulations below, amounts are stated to the nearest dollar. PERIOD FROM: Start l;
Use Column I on Contracts where variable retains a for line items may apply.
g Y TO: Finish
ARCHITECT'S PROJECT NO: k..
F.<
A B C D E F G H I'
ITEM DESCRIPTION OF WORK SCHEDULED WORK COMPLETED TOTAL COMPLETED;
This Application AND STORED BALANCE RETAINAGE
;o. VALUE TO FINISH
Previous TO DATE (C -C)
Applications Work in Place Stored Materials (D +E +F) (C —G)
(not in Do r E)
i
CO#1 10. Non Skid Epoxy Floor 7,855.00 7,855.00 -0- -0- 7,855.00 100 -0-
11. Relocate Roof Drain 690.00 690.00 -0- -0- 690.00 100 -0-
i
12. Electric Heat 12,381.00 12,381.00 -0- -0- 12,381.00 100 -0-
s:
CO #2 han e Order No. 2
g
1. Feed Hopper Drain f`
Line 2,090.00 2,090.00 -0- -0- 2,090.00 100 0
4•:
2. Reroute 1" Seal Wate t`
Line 556.00 556.00 -0- -0- 556.00 100 -0-
r,
3. Move Electric for
Polymer 484.00 484.00 -0- -0- 484.00 100 -0-
r,•;
4. Electrical Modifica-
tions 1,699.00 1,699.00 -0- -0- 1,699.00 100 -0-
C0#3 Change Order No. 3
1. Bioway Filters 98,900.00
2. Step Screen install. 40,825.00 40,825.00 -0- -0- 40,825.00 100 -0-
3. Precast Concrete
U.V. Tank 32,050.00 32,050.00 -0- -0- 32,050.00 100 -0-
•r.:
c'
NN
k:.
K'.
892,711,25. 838,691.25 -0- -0- 838,691.25 94 54,020.00 -0- s`
AIA DOCUMENT G703 CONTINUATION SHEET APRIL 1978 EDITION AIA'b rK) 1978
THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YOPK AVE., N.W., WASHINGTON. D.C. :0006 6703 1978
EXHIBIT D
CONTRACTOR'S AFFIDAVIT
Final Estimate
STATE OF Indiana
)ss
County of Madison
The undersigned, M. K. Betts Engineering Contracting, Inc.
t hereby represents that on October 19, 2005 it was awarded
a contract by City of Carmel, Indiana, hereinafter called the Owner, to
WWTP Improvements, Gravity Belt Thickener Facility, Contract 56 in
accordance with terms and conditions of Contract No. 56 and the undersigned
further represents that the subject work has now been accomplished and the
said Agreement has now been completed.
The undersigned hereby warrants and certifies that all of its
indebtedness arising by reason of the said Agreement has been fully paid or
satisfactorily secured; and that all claims from Subcontractors and others
for labor and material used in accomplishing the said project, as well as all
other claims arising from the performance of the said Agreement, have been
fully paid or satisfactorily settled. The undersigned further agrees that,
if any such claim should hereafter arise, he (it) shall assume responsibility
I for the same immediately upon request to do so by the Owner.
The undersigned, for a valuable consideration, the receipt of which is
hereby acknowledged, does further hereby waive, release and relinquish any
and all claims or right of lien which the undersigned now has or may
hereafter acquire upon the subject premises for labor and material used in
accomplishing said project owned by the Owner.
This affidavit is freely and voluntarily given with full knowledge of
the facts, on this 30th day of June A.D. 2008
M. K. Betts Engineering Contracting Inc.
or
By a
Title D avid D. Grimes, Secretary
Subscribed and sworn to before me this 30th day of June
A.D. 20 08
Theresa M. Stires Notary Public
(Seal)
My Commission Expires October 28, 2 015
i.
contruc \other \9970.doc
951 -5755 A -A -10
Hrescnoea oy JIate tfoara OT Accounts %.Uy rvini rvv. cv i k—v iv—)
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
351429
M.K. BETTS ENGINEERING CONTR Purchase Order No.
P.O. Box 2533 Terms
Anderson, IN 46018 Due Date 8/15/2008
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
8/15/2008 22 $7,500.00
hereby certify that the attached invoice(s), or bill(s) is (are) true and
orrect and I have audited same in accordance with IC 5- 11- 10 -1.6
Date icer
✓O'UCHER 086123 WARRANT ALLOWED
35'1429 IN SUM OF
M.K. BETTS ENGINEERING CONTR
'.O. Box 2533
4nderson,IN 46018
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
22 07- 1050 -69 $7,500.00
Q
00
t4
Voucher Total $7,500.00
Cost distribution ledger classification if
claim paid under vehicle highway fund