HomeMy WebLinkAbout161937 07/23/2008 CITY OF CARMEL, INDIANA VENDOR: 00351429 Page 1 of 1
ONE CIVIC SQUARE M.K. BETTS ENGINEERING INC
CARMEL, INDIANA 46032 PO BOX 2533 CHECK AMOUNT: $37,425.50
ANDERSON IN 46018 CHECK NUMBER: 161937
CHECK DATE: 7123/2008
D EPARTMENT ACCOU PO NU INV OICE NUMBER AMOUNT DESC
659 5023990 11 2,603.00 1050.79
659 5023990 12 34,822.50 1050.79
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APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT 6702 (1,stwct side) P, O"F 01 il\cl
ions on reverse ;C"
TO (OWNER): City of Carmel PROJECT: Solar Drying APPLICATION NO. Twelve (I 2)DIstribution to.
One Civic Square Contract 65 Retainage
7 Cv•NER
Carmel, IN 46032 Carmel, IN PERIOD TO: f RCHITECT
CONTRACTOR
FROM (CONTRACTOR): VIA (ARCHITECT): ARCHITECT'S
M. K. Betts Engineering Jones Henry Engineers, Ltd. PROJECT NO:
Contracting, Inc.
CONTRACT FOR:
Invoice No. 07-232.12 Ret. CONTRACT DATE:
Application is made for Payment, as shown below, in connection with th Contract
CONTRACTOR'S APPLICATION FOR PAYMENT Continuation Sheet, AIA Document G703, is attached.
CHANCE ORDER SUMMARY j 1. ORIGINAL CONTRACT SUM 5 696,450.00
Change Orders approved in I ADDITIONS DEDUCTIONS 2. Net change by Change Orders 5 125,900.00
previous months by Owner 3. CONTRACT SUM TO DATE (Line 1 2) 5_ 822,350.00
TOTAL 4. TOTAL COMPLETED STORED TO DATE S 822,350.00
Approved this Month (Column G on G703)
Number Date Approved 5, RETAINAGE:
a. of Completed Work S
I CO#1 $127,916.00 $2,016.00 (Column D E on G703)
b. of Stored Material
(Column F on G703)
Total Retainage (Line 5a 5b or
S -0-
$2,016.00 Total in Column I of G
TOTALS $127, 16.0 822,350.00
.Net thane by Change Orders $125,900.00 6. TOTAL EARNED LESS RETAINAGE
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) S 787,527.50
paid by the Contractor for Work for which previous Certificates for Payment were 8. CURRENT PAYMENT DUE S 34,822.50
issued and payments received from the Owner, and that current payment shown 9. BALANCE TO FINISH, PLUS RETAINAGE S -0-
herein is now due.
(Line 3 less Line 6)
CONTRACTOR: M. K. Betts Engineering Contracting, Inc. State or: Indiana County of: Madison
Subscribed and sworn to before me this 24th day of June 1 2008
Notary Public:
Bv:
Date: June 24, 2008 My Commission expires: October 28 2015
L
7
AMOUNT CERTIFIED S
ARCHITECTS CERTIFICATE FOR PAYMENT (Attach explanation if amount certified differs from the amount a,opheci fC-'.
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:
indicated, the quality of the Work is in accordance with the Contract Documents, and
This is Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
the Contractor is entitled to payment of the AMOUNT CERTIFIED. virh(
Contractcr named herein. Issuance, payment and acceptance of pavment arc )Ui
prejudice TO a n v ri g hts of the
CONTINUATION SHEET AIA DOCUME 0 703 Carmel WWTP Solar D rying Contract 65 PAGE OF PAGES K
j AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing APPLICATION NUMBER: Twelve (12) Ret.
Contractor's signed Certification is attached. APPLICATION DATE: 06- 24 -08::
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
r.
ARCHITECT'S PROJECT NO:
A B C D E F G H I
WORK COMPLETED•
T OTAL COMPLETED
ITEM DESCRIPTION OF WORK SCHEDULED This Application AND STORED of BALANCE RETAINAGE i.
VALUE TO FINISH
Previous TO DATE (G =C)
Applications Work in Place Stored Materials (C—G)
(D+E-+•F)
(not in D or E)
L•
f
1. Mobilization, Bond
Insurance 20,000.00 20,000.0 —0— —0— 20,000.00 100 —0— r
2. Topsoil Embankment
850 cy $15.66/cy 1.3,311.00 13,311.00 -0- -0- 13,311..00 100 -0-
Y..
3. Removal of Biosolids
1.1.00 cy $6.48/cy 7,128.00 7,128.00 —0— —0— 7,128.00 100 —0—
4. Excavation, fill
embankment b:
5900 cy $6.48/cy 38,232.00 38,232.00 -0- -0- 38,232.00 100 -0
5. Site Demo, Piping, Etc. 79,000.00 79,000.00 -0- -0- 79,000.00 100 -0-
6. Building Exc. Backfil 45,000.00 45,000.00 -0- -0- 45,000.00 100 -0-
7. Concrete Drying Bldg
and Control 237,000.00 237,000.00 -0- -0- 237,000.00 100 -0-
8. Dock Extension 6,250.00 6,250.00 -0- -0- 6,250.00 100 -0
9. Building Erection 84,200.00 84,200.00 -0- -0- 84,200.00 100 -0-
10. Hot Water Piping 33,800.00 33,800.00 -0- -0- 33,800.00 100 -0- i::•
I
17.. Waterlines 1.3,450.00 13,450.00 -0- -0- 13,450.00 100 -0-
12. Miscellaneous 7,579.00 7,579.00 -0- -0- 7,579.00 100 -0-
13. Asphalt Paving 24,000.00 24,000.00 -0- -0- 24,000.00 100 -0- e.
14. Electrical 87,500.00 87,500.00 -0- -0- 87,500.00 100 -0-
r.:
AIA DOCUMENT G703 CONTINUATION SHEET APRIL 1978 EDITION AIAZ CU 1978
THE AMERICAN INST'tTUTE OF ARCHITECTS, 1735 NEW YORK, AVE., N.W., WASHINGTON. D.C. 1 _0006 G703 1978
CONTINUATION SHEET AIA DOCUMEN 0 703 PAGE OF PAGES
,AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing APPLICATION NUMBER: Twelve (12 Ret.
Contractor's signed Certification is attached. APPLICATION DATE: 06 24 -08
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:
1
A B C D E F G H I
WORK COMPLETED
1
ITEM DESCRIPTION OF WORK SCHEDULED TOTAL COMPLETED BALANCE BALANCE RETAINAGE
^'o. VALUE This Application AND STORED o TO FINISH
Previous TO DATE (G =C)
Applications Work in Place Stored Materials (D +E +F) (C —G)
(not in D or E)
15. Change Order No. 1
i 1. Adjust Final Dirt
j Quantity 12,798.00 12,798.00 -0- -0- 12,798.00 100 -0-
j 2. Backflow Preventer,
Piping, Etc. 26,500.00 26,500.00 -0- -0- 26,500.00 100 -0-
3. Dock Lights 5,740.00 5,740.00 -0- -0- 5,740.00 100 -0-
i
4. Heating Lines
Conduit 48,000.00 48,000.00 -0- -0- 48,000.00 100 -0-
5. 40 amp Breaker 2,755.00 2,755.00 -0- -0- 2,755.00 100 -0-
6. MCC Cover
s Centrifuge 748.00 748.00 -0- -0- 748.00 100 -0-
7. Relcoate Fence
Firing Range 1,256.00 1,256.00 -0- -0- 1,256.00 100 -0-
1 8. Additional Asphalt 22,780.00 22,780.00 -0- -0- 22,780.00 100 -0-
I:
9. Remove Lift Station
Structure 1,100.00 1,100.00 -0- -0- 1,100.00 100 -0-
10. Contour N. Edge of
Lagoon 1,620.00 1,620.00 -0- -0- 1,620.00 100 -0-
11. Rental of City
Boomtruck 2,016.00 2,016.00 -0- -0- 2,016.00 100 -0- p.
12. Revised Ridge Cap 792.00 792.00 -0- -0- 792.00 100 -0-
13. Intermediate Gutter
Cap 1,026.00 1,026.00 -0- -0- 1,026.00 100 -0-
i
AIA DOCUMENT 0703 CONTINUATION SHEET APRIL 1978 EDITION AIA'- s) 1978
THE A.V,LRICA'� INSTITL:TE OF ARCHITECTS. 1735 NEW YORE: AVE.. N.W.. WASHINGTON. D C. G %off 1978
CONTINUATION SHEET AIA D 0 PAGE O PA GES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing APPLICATION NUMBER: Twelve (12) Ret
Contractor's signed Certification is attached. APPLICATION DATE: 06- 24 -08;
In tabulations below, amounts are stated to the nearest dollar. PERIOD FROM: Start n'
1 Use Column I on Contracts where variable retainage for line items may apply. TO: Finish
.1 ARCHITECT'S PROJECT NO: v.
A B C D E F G H I..
WORK COMPLETED
ITEM DESCRIPTION OF WORK SCHEDULED TOTAL COMPLETED o BALANCE RETAINAGE
This Application AND STORED
.o. VALUE Previous TO DATE (G =C) TO FINISH
Applications Work in Place Stored Materials (D +E +F) (C —G)
(not in D or E)
14. Wood Fillers
Control Joints 753.00 753.00 —0— —0— 753.00 100 —0
c
15. Insulate Gutters 503.00 503.00 -0- -0- 503.00 100 -0
16. Alum. Sheetmetal
Foundation 145.00 145.00 -0- -0- 145.00 100 -0- h
I
17. Downspouts to Lagoon 1,400.00 1,400.00 -0- -0- 1,400.00 100 -0-
I f•
j'.
f
822,350.00 1 822050.00 -0- 1 -0- j 822,350.00 100 -0- 0
AIA DOCUMENT G703 CONTINUATION SHEET APRIL 1978 EDITION AIA'" s1 1978
THE AM E RICA N INSTITUTE OF ARCHITECTS, 1735 NEW YORK: AVE.. N.W. WA�H1N(.,TnN i7 C '7)0r` r- -nom
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.
R
Payee
351429
M.K. BETTS ENGINEERING CONTR Purchase Order No.
P.O. Box 2533 Terms
Anderson, IN 46018 Due Date 7/15/2008
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
7/15/2008 12 $34,822.50
hereby certify that the attached invoice(s), or bill(s) is (are) true and
3orrect and I have audited same in accordance with IC 5- 11- 10 -1.6
Date Officer
VOUCHER 085904 WARRANT ALLOWED
351429 IN SUM OF
M.K. BETTS ENGINEERING CONTR
P.O. Box 2533
Anderson, IN 46018
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
12 07- 1050 -79 $34,822.50
-C Jed i :A,
Voucher Total $34,822.50
Cost distribution ledger classification if
claim paid under vehicle highway fund
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
351429
M.K. BETTS ENGINEERING CONTR Purchase Order No.
P.O. Box 2533 Terms
Anderson, IN 46018 Due Date 7/15/2008
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
7/15/2008 11 $2,603.00
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 Officer
t °VOUCHER 085910 WARRANT ALLOWED
351429 IN SUM OF
M.K. BETTS ENGINEERING CONTR
P.O. Box 2533
Anderson, IN 46018
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
11 07- 1050 -79 $2,603.00
('O�JNec 4 'oti
Voucher Total $2,603.00
Cost distribution ledger classification if
claim paid under vehicle highway fund
CONTINUATION SHEET AIA DOCUMENT 0703 Carmel WWTP Solar Dryi Contract 65 PA GE OF
j AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing APPLICATION NUMBER: Eleven (11)
1 Contractor's signed Certification is attached. APPLICATION DATE: June 24, 2008
In tabulations below, amounts are stated to the nearest dollar. PERIOD FROM: 05 01 08
Use Column I on Contracts where variable retainage for line items may apply. TO: 06 -24 08
i
ARCHITECT'S PROJECT NO:
A B C D E F G H
E
WORK COMPLETED TOTAL COMPLETED BALANCE RETAIN P
ITEM DESCRIPTION OF WORK SCHEDULED This Application AND STORED
No. VALUE PP TO FINISH
(G =C) (C —G)
Stored Materials
Previous TO DATE
Applications Work in Place (D +E +F)
(not in D or E)
4
1. Mobilization, Bond
Insurance 20,000.00 20,000.0 —0— —0— 20,000.00 100 —0—
2. Topsoil Embankment
850 cy $1.5.66/cy 1.3,311.00 13,311.00 —0— —0— 1.3,311.00 100 0
3. Removal of Biosolids
1.1.00 cy $6.48/cy 7,128.00 7,128.00 —0— —0— 7,128.00 100 —0-
4. Excavation, fill
embankment
c
5900 cy $6.48/cy 38,232.00 38,232.00 -0- -0- 38,232.00 100 -0-
5. Site Demo, Piping, Etc. 79,000.00 79,000.00 -0- -0- 79,000.00 100 -0-
6. Building Exc. Backfill 45,000.00 45,000.00 -0- -0- 45,000.00 100 -0-
7. Concrete Drying Bldg
and Control 237,000.00 237,000.00 -0- =0- 237,000.00 100 -0
8. Dock Extension 6,250.00 6,250.00 -0- -0- 6,250.00 100 -0
9. Building Erection 84,200.00 84,200.00 -0- -0- 84,200.00 100
-0'
10. Hot Water Piping 33,800.00 33,800.00 -0- -0- 33,800.00 100
1.1. Waterlines 1.3,450.00 13,450.00 —0— —0— 13,450 100
—O
12. Miscellaneous .7,579.00 7,579.00 —0— —0— 7,579.00 100
1.3. Asphalt Paving 24,000.00 24,000.00 —0— —0— 24,000.00 100
-O
14. Electrical 87,500.00 87,500.00 -0- -0- 87,500.00 100
AIA DOCUMENT G703 CONTINUATION SHEET APRIL 1978 EDITION AIAD CU 1978
THE A.V.ERICAN'INSTITUT`E OF ARCHITECTS, 1735 NEW YORK AVE.. N.W.. WASHINGTO\'. D.C. 1_0006
3
CONTINUATION SHEET AIA DOCUMENT C PAGE OF PAGES
i
AIA Document 0702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing APPLICATION NUMBER: Eleven (11)
Contractor's signed Certification is attached. APPLICATION DATE: June 24, 2008
In tabulations below, amounts are stated to the nearest dollar. PERIOD FROM: 05 01 08
Use Column I on Contracts where variable retainage for line items may apply. TO: 06 24 08 p'
3
j ARCHITECT'S PROJECT NO:
1
A B C D E F G H I
1 i•.
i WORK COMPLETED
COMPLETED
ITEM DESCRIPTION OF WORK SCHEDULED BALANCE RETAINAGE
This Application AND STORED a
No. VALUE Previous TO DATE (G =C) TO FINISH
Stored Materials (C —G)
1
Applications Work in Place (not in D or E) (D +E +F)
I
14. Wood Fillers
Control Joints 753.00 -0- 753.00 -0- 753.00 100 -0-
C-
15. Insulate Gutters 503.00 -0- 503.00 -0- 503.00 100 -0-
16. Alum. Sheetmetal
Foundation 145.00 -0- 145.00 -0- 145.00 100 -0-
i
17. Downspouts to Lagoon 1,400.00 -0- 1,400.00 -0- 1,400.00 100 -0
3
1
is
822,350.00 819,747.00 2,603.00 -0- 822,350:00 100 -0- 34,822.50:;'
AIA DOCUMENT G703 CONTINUATION SHEET APRIL 1978 EDITION AIA'b rs) 1978
THE \.VERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE., N.W.. WASHINGTON. D.0 'nOnr,
CONTINUATION SHEET AIA D OCUME NT 0 703 PAGE O PAGES t
'r
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing APPLICATION NUMBER: Eleven (11)
Contractor's signed Certification is attached. APPLICATION DATE: June 24, 2008
In tabulations below, amounts are stated to the nearest dollar. PERIOD FROM: 05 -01 -08
Use Column I on Contracts where variable retains a for line items may apply. 8 Y PP Y• TO: 06 24
i
ARCHITECT'S PROJECT NO:
L
A B C D E F G H I
WORK COMPLETED
T OTAL COMPLETED
ITEM DESCRIPTION OF WORK SCHEDULED BALANCE RETAINAGE
This Application AND STORED
o. VALUE TO FINISH
Previous TO DATE (G U
(C—G)
Stored Materials
Applications Work in Place (D +E +F)
(not in D or E)
15. Change Order No. 1;.
1. Adjust Final Dirt
Quantity 12,798.00 12,798.00 —0— —0— 12,798.00 100 —0—
I t
2. Backflow Preventer,
Piping, Etc. 26,500.00 26,500.00 —0— —0— 26,500.00 100 —0— f'
3. Dock Lights 5,740.00 5,740.00 —0— —0— 5,740.00 100 —0—
x:.
4. Heating Lines
Conduit 48,000.00 48,000.00 —0— —0— 48,000.00 100 —0—
l;
j S. 40 amp Breaker 2,755.00 2,755.00 —0— —0— 2,755.00 100 —0—
1 6. MCC Cover
s Centrifuge 748.00 748.00 0 748.00 100
7. Relcoate Fence
Firing Range 1,256.00 1,256.00 —0— —0— 1,256.00 100 —0
j 8. Additional Asphalt 22,780.00 22,780.00 —0— —0— 22,780.00 100 —0-
9. Remove Lift Station
Structure 1,100.00 1,100.00 —0— —0— 1,100.00 100 —0— s'
s,•
10. Contour N. Edge of
Lagoon 1,620.00 1,620.00 —0— —0— 1,620.00 100 —0—
c;:
11. Rental of City
Boomtruck 2,016.00 —0— 2,016.00 —0 2,016.00 100 —0—
t
12. Revised Ridge Cap 792.00 —O— 792.00 0— 792.00 100 —0— E
13. Intermediate Gutter
Cap 1,026.00 1 —0— 1,026.00 —0— 1,026.00 100 —0—
AIA DOCUMF,NT G703. CONTINUATION SHEET APRIL 1978 EDITION AIA' rrO 1978
THE AN.ERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE_ ".W- WASH INGTON. O.C. '_000G ln�
CONTINUATION SHEET A/A DOCUMENT G703 Carmel WWTP Solar Drying Contract 65 PAGE OF PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing APPLICATION NUMBER: Eleven (11.)
Contractor's signed Certification is attached. APPLICATION DATE: June 24, 2008
In tabulations below, amounts are stated to the nearest dollar. PERIOD FROM: 05 -01 -08
Use Column I on Contracts where variable retainage for line items may apply. TO: 06 -24 -08
ARCHITECT'S PROJECT NO:
A B C D E F G H I
WORK COMPLETED TOTAL COMPLETED
ITEM DESCRIPTION OF WORK SCHEDULED This Application AND STORED qi BALANCE RETAINAGE
N0. VALUE TO FINISH
Previous Stored Materials TO DATE (G =C) (C —G)
Applications Work in Place (D +E +F)
(not in D or E)
1. Mobilization, Bond
Insurance 20,000.00 20,000.0 -0- -0- 20,000.00 100 -0-
2. Topsoil Embankment
850 cy $15.66/cy 1.3,311..00 13,311.00 -0- -0- 1.3,311.00 100 -0-
3. Removal of Biosolids
1.1.00 cy $6.48/cy 7,128.00 7,128.00 -0- -0- 7,128.00 100 -0-
4. Excavation, fill
embankment
5900 cy $6.48/cy 38,232.00 38,232.00 -0- -0- 38,232.00 1.00 -0-
5. Site Demo, Piping, Etc. 79,000.00 79,000.00 -0- -0- 79,000.00 100 -0- ,F
6. Building Exc. Backfill 45,000.00 45,000.00 -0- -0- 45,000.00 100 -0-
7. Concrete Drying Bldg
and Control 237,000.00 237,000.00 -0- -0- 237,000.00 100 -0-
8. Dock Extension 6,250.00 6,250.00 -0- -0- 6,250.00 100 -0-
9. Building Erection 84,200.00 84,200.00 -0- -0- 84,200.00 100 -0-
10. Hot Water Piping 33,800.00 33,800.00 -0- -0- 33,800.00 100 -0-
i-
1.1. Waterlines 1.3,450.00 13,450.00 -0- -0- 13,450.00 100 -0-
1.2. Miscellaneous 7,579.00 7,579.00 -0- -0- 7,579.00 100 -0-
13. Asphalt Paving 24,000.00 24,000.00 -0- -0- 24,000.00 100 -0-
14. Electrical 87,500.00 87,500.00 -0- -0- 87,500.00 100 0
is
AIA DOCUMENT G703 CONTINIJATION SHEET APRIL 1978 EDITION AIAa QJ 1978
THE A.MERICAN•INSTITUTt OF ARCHITECTS, 1735 NEW YORK AVE.. N.W.. WASHINGTON. D.C. 20006 r:-n? 107P
3 i
APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT 0 702 (Instructions on reverse sides
T ut`�o
O (OWNER): City of Carmel PROJECT: Solar Drying APPLICATION NO: Eleven( 11)D st ri'ti
One Civic Square Contract 65 O'
Carmel, IN 46032 Carmel, IN PERIOD TO: 06 08 \R(' .,CMG
C O'
t T
FROM (CONTRACTOR): VIA (,ARCHITECT): ARCHITECT'S
.f
M. K. Betts Engineering Jones Henry Engineers,. Ltd. PROJECT NO:
Contracting,. Inc.
1 C ONTRACT FOR:
1 .y Invoice No. 07- 232.11 CONTRACT DATE: o r<
CONTRACTOR'S APPLICATION FOR PAYMENT Continuation Sh et, f AIA D cu G703,,iss altt achedconnection with tr e
CHANGE ORDER SUMMARY 1. ORIGINAL CONTRACT SUM S 696,450
I I Net change b Change Orders 125 900 •0
Change Orders approved in ADDITIONS DEDUCTIONS 2 g y g S �0
previous months by Owner 3. CONTRACT SUM TO DATE (Line 1 2) S 822 350 0
TOTAL 4. TOTAL COMPLETED STORED TO DATE S 822 350
Approved this Month (Column G on G703)
Number Da Appr oved 5. RETAINAGE:
a. of Completed Work S`
I CO#1 $127,916.00 $2,016-00 (Column D E on G703)
I b. of Stored Material 5
(Column F on G703)
Total Retainage (Line 5a 5b or g 22
TO
TAts $127,916.00 $2,016.00 Total in Column i of G703 5 7 g7,52�
Net change by Change Orders $125,900.00 6. TOTAL EARNED LESS RETAINAGE
The undersigned Contractor certifies that to the best of the Contractor's knowledge, (Line 4 less Line 5 Total) 2'4 50 O
information and belief the Work covered by this Application for Payment has been 7. LESS PREVIOUS CERTIFICATES FOR 78� 9 0
completed in accordance with the Contract Documents, that all amounts have been PAYMENT (Line 6 from prior Certificate)
paid by the Contractor for Work for which previous Certificates for Payment were 8. CURRENT PAYMENT DUE S 34 822
issued and payments received from the Owner, and that current payment shown 9. BALANCE TO FINISH, PLUS RETAINAGE S
herein is now due. (Line 3 less Line 6)
Madis0
CONTRA R: M. K. Betts Engineering Contracting, Inc. State of: Indiana County of: o( _junk
Subscribed and sworn to before me this 24th d
Notary Public:
By: z Y /5 Z 0 Date: June 24, 2008 My Commission expires: October 28 2015
AMOUNT CERTIFIED 5 z 6 L
ARCHITECT'S CERTIFICATE FOR PAYMENT (Attach explanation if amount certified differs iron the amount aPP
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: D ate
indicated, the quality of the Work is in accordance with the Contract Documents, and This Certificate is not negotiable. Tt,�
the Contractor is entitled to payment of the AMOUNT CERTIFIED. Contractcr