160965 06/25/2008 CITY OF CARMEL INDIANA VENDOR: 00351429 Page 1 of 1
ONE CIVIC SQUARE M.K. BETTS ENGINEERING INC
o CARMEL, INDIANA 46032 PO BOX 2533 CHECK AMOUNT: $352,320.30
ANDERSON IN 46018 CHECK NUMBER: 160965
CHECK DATE: 6/2512008
DEPARTMENT A CCOUNT PO N UMBER INVOICE NUMBER AMOU DESCRIPTION
654 R5023990 S10726 7 352,320.30 CONSTRUCTION
t;
APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT 07 (Instructions on reverse side) PAGE ONE OF PAGES
TO (OWNER): City of Carmel PROJECT: Blower/ Electrical Modification APPLICATION NO: Seven (7) Distribution to:
One Civic Square Contract 60 C OWNER
Carmel, IN 46032 PERIOD TO: 05 31 08 C ARCHITECT
C CONTRACTOR
;S FROM (CONTRACTOR): VIA (ARCHITECT): ARCHITECT'S C
t M. K. Betts Engineering PROJECT NO: C
Contracting, Inc.
CONTRACT FOR: Invoice No. 07- 262.07 CONTRACT DATE:
i
CONTRACTOR'S APPLICATION FOR PAYMENT Continua ion Sh et, Document G703nisbatto ched connection with the Contract.
CHANGE ORDER SUMMARY 1. ORIGINAL CONTRACT SUM 5 2 349,000.00
Change Orders approved in ADDITIONS DEDUCTIONS 2. Net change by Change Orders S —0
previous months by Owner 3. CONTRACT SUM TO DATE (Line 1 -2) 5 2,349,000.00
TOTAL 4. TOTAL COMPLETED STORED TO DATE S 1,082,311-33
Approved this Month (Column G on G703)
1 Number Date Approved 5. RETAINAGE:
a. 1 of Completed Work S 88,439.43
f (Column D E on G703)
b. 10 of Stored Material 19,791.70
(Column F on G703)
Total Retainage (Line 5a 5b or
A TOTALS Total in Column I of G703) S 108,231 .13
6. TOTAL EARNED LESS RETAINAGE
Netchan ebvChange Orders 974,080.20
The undersigned Contractor certifies that to the best of the Contractor's knowledge, (Line 4 less Line S 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) 21 759.90
paid by the Contractor for Work for which previous Certificates for Payment were 8. CURRENT PAYMENT DUE S 352,320.30
issued and payments received from the Owner, and that current payment shown 9. BALANCE TO FINISH, PLUS RETAINAGE 5 1374 .919.80
herein is now due. (Line 3 less Line 6)
CONTRA OR: M. K. Betts Engineering Contracting, Inc. State of: Indiana County of: Madison
a Subscribed and sworn to before me this 31st day of May 2008
j Notary Public:
Bv: —Date: May 31 2008 My Commission expires: October 28 2015
I
AMOUNT CERTIFIED
ARCHITECT'S CERTIFICATE FOR PAYMENT 5
(Attach explanation !i 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���� t
best of the Architect's knowledge, information and belief the Work has progressed as By: -1 Date:
t indicated, the quality of the Work is in accordance with the Contract Documents, and
This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
the Contractor is entitled to payment of the AMOUNT CERTIFIED.
Contractcr named herein. Issuance, payment and acceptance of payment are without
prejudice to any rights of the Owner or Contractor under this Contract.
AAA OOCU.MENT 6702• A PI LCATI(• 1 ,a :D CERTIF IC 1TE. FOR PA)N1E I 1. 1 EDI TION 41A' 1981
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 6/20/2008
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
6/20/2008 7 $352,320.30
hereby certify that the attached invoice(s), or bill(s) is (are) true and
;orrect and I have audited same in accordancewith IC 5- 11- 10 -1.6 y
Date Of r
VOUCHER 085762 WARRANT ALLOWED
351429 IN SUM OF
MAK. 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
7 09- 1050 -61 $352,320.30
C'0 N51Q.uc
P
Voucher Total $352,320.30
roost distribution ledger classification if
claim paid under vehicle highway fund
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