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Home My WebLink About167455 12/23/2008 CITY OF CARMEL, INDIANA VENDOR: 356934 Page 1 of 1 s 0 ONE CIVIC SQUARE SIGNATURE CONSTRUCTION LLC CHECK AMOUNT: $6,115.48 4. CARMEL, INDIANA 46032 720 3RD AVE SW CARMEL tN 46032 CHECK NUMBER: 167455 CHECK DATE: 12I2312D08 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBE AMOUNT DESCRIPTION 902 4460805 14 6,116.48 RETAIL SITE #5 I 4 PARTIAL Payment to Follow AFFIDAVIT AND WAIVER OF LIEN STATE OF INDIANA SS: COUNTY OF HAMILTON Tom Koontz being duly sworn states that he is the President of SIGNATURE CONSTRUCTION, LLC having contracted to furnish certain materials and /or labor as follows: Site Development for a project known as Parcel 5B Phase I Carmel City Center Motor Court located at CARMEL, IN and owned by Carmel Redevelopment Commission and does further state: PARTIAL WAIVER: that the balance due from the owner is the sum of six thousand one hundred sixteen dollars and forty -eight cents (6,116.48) the payment of which has been promised as the sole consideration for this Affidavit and Partial Waiver of Lien which is given to and for said amount, effective upon receipt of such payment. THEREFORE, the undersigned waives and releases unto the Owner of said premises any and all lien or claim whatsoever on the above described property and improvements thereon on account of labor or material or both, furnished by the undersigned thereto, and further certifies that no other party has a any claim or right to a lien on account of any work performed or material furnished to the undersigned for said project, and within the scope of this affidavit and waiver. SIGNATURE CONSTRUCTION, LLC =y f TJn Koontz President Subscribed and sworn to before me this: 71,4a �00 Notary Public :r.,ce�i LINDABUCHANAN Hancock County oTnav My Commission Expires August 20,2011.,.,, x;: APPLICATION AND CERTIFICATION FOR PAYMENT 41A DOCUM0NTG702 PAGE ONE OF 2 PAGES TO OWNER Carmel Redevelopment Commissic PROJECT: Parcel 5H APPLICATION NO Draw Number 14 Distribution to: One Civic Square Phase I Carmel City Center Signature costs =OWNER Carmel, Indiana 46032 Motor Court ARCHITECT PERIOD TO: 12/1/2008 LJ CONTRACTOR FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design Signature Construction LLC 720 3rd Avenue S.W. PROJECT NOS: CSO Project 4 21010 Carmel, Indiana 46032 CONTRACT FOR: CONTRACT DATE 9/7/2007 CONTRACTOR'S APPLICATION FOR PAYMENT The undersi Contractor certifies that to the best ofthe Contractor's knowled Application is made for payment, as shown below, in connection with the Contract. information and belief the Work covered by this Application for Payment has been Continuation Sheet, AIA Document 6703, is attached. completed 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 payments received from the Owner, and that current payment shown herein is now due. I. ORIGINAL CONTRACT SUM 2,841,863.00 2. Net change by Change Orders 0.00 CONTRACTOR: 3. CONTRACT SUM TO DATE (Line 1 t 2) 2,841,863.00 4. TOTAL COMPLETED STORED TO 2,549,149.09 (u bscribed Date: Z$ 5. RETAINAGE: Tom Ko President a. 0.099 of Completed Work 251,848.9] a swom to before me this 5nd day of Nov, 2008 (Column D E on G703) b. of Stored Materia] LINDA BUCHANAN (Column F on G703) N ora r Hancock County Total Retainage (Lines Sa Sb or -s. SEAL My Commission Expires Total in Column 1 of G703) 251,848,91 t August 20, 2011 6. TOTAL EARNED LESS RETAINAGE 2,297,300.18 In accordance with the Contract Documents, based on on -site observations and the data (Line 4 Less Line 5 Total) comprising the application, the Architect certifies to the Owner that to the best of the 7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge, information and belief the Work has progressed as indicated, PAYMENT (Line 6 from prior Certificate) 2,291,183.70 the quality of the Work is in accordance with the Contract Documents, and the Contractor 8. CURRENT PAYMENT DUE S 6, l 16.48 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH, INCLUDING RETAINAGE 544,562.82 (Line 3 less Line 6) AMOUNT CERTIFIED. 6 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Att&nn ex amount ceriified difjers from the amoum applied Initial a!l frgures on this Total changes approved App C uai/on Sheei that are changed to con form u the amount certified) in previous months by Owner AR Total approved this Month By: Date: OP TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable y to the contractor named herem. Issuance, payment and acceptance of payment are without NET CHANGES by Change Order $0.00 prejudice to any rights of the Owner or Contractor under this Contract. AIA DOCUMENT G702 APPLICATION AND CERTIFICATION FOR PAYMENT 1992 EDITION AIA C1992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE.. N.W., WASHINGTON, DC 20006 -5292 Users may obtain validation of this document by requesting a completed AIA Document D401 Certification of Document's Authenticity from the Licensee. G703 CONTINUATION SHEET Page 2 of 2 ri To: From: Project: Application No.: 16 Carmel Redevelopment Commission Signature Construction LLC Parcel 5B Application Date: 1211108 One Civic Square 720 3rd Avenue S.W. Phase I Carmel City Center Period To: 1211108 Carmel, Indiana 46032 Carmel, Indiana 46032 Motor Court Engineer's Project No. A B C D E F G H I Work Com leted Materials Total Presently Completed Balance Retainage Item Scheduled From Previous Stored and Stored 9 To If 11 Description of Work Value Application This Period (Not in To Date (G /C) Finish variable D or E) (D +E +F) (C -G) 101 General Requirement 132,109.09 117,577.09 1,321.09 0.00 118,898.18 90% 13,210.91 11,889.82 Bonding 113,675.00 113,675.00 0.00 0.00 113, 675.00 100% 0.00 11,367.50 Insurance 25,000.00 25,000.00 0.00 0.00 25,000.00 100% 0.00 2,500.00 102 Existing Conditions 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 103 Concrete 2,170,090.00 2,157,460.00 5,475.00 0.00 2,162,935.00 100% 7,155.00 216,293.50 104 Masonry 50,000.00 0.00 0.00 0.00 0.00 0% 50,000.00 0.00 105 Metals 19,368.00 0.00 0.00 0.00 0.00 0% 19,368.00 0.00 106 Wood, Plastics and Composites 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 107 Thermal and Moisture Protection 68,430.00 30,660.00 0.00 0.00 30,660,00 99% 37,770.00 0.00 108 Openings 6,100.00 0.00 0.00 0.00 0.00 0% 6,100.00 0.00 109 Finishes 26,360.00 0.00 0.00 0.00 0.00 0% 26,360.00 0.00 110 Specialties 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 111 Equipment 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 112 Furnishings 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 113 Special Construction 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 114 Conveying Equipment 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 121 Fire Suppression 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 122 Plumbing 31,000.00 0.00 0.00 0.00 0.00 0% 31,000.00 0.00 123 Heating, Ventilation AC 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 125 Integrated Automation 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 126 Electrical 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 127 Communications 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 128 Electronic Safety Security 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 131 Earthwork 89,640.00 0.00 0.00 0.00 0.00 0% 89,640.00 0.00 132 Exterior Improvements 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 133 Utilities 0.00 0.00 0.00 0:00 0.00 0% 0.00 0.00 134 Transportation 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 140 Process Integration 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 141 Material Processing Handling Equip. 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 144 Pollution Control Equipment 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00 Construction Fee 110,090.91 97,980.91 (0.00) 0.00 97,980.91° 89% 12,110.00 9,798.09 2,841,863.00 2,542,353.00 6,796.09 0.00 2,549,149.09 1 90% 292,713.91 251,848.91 Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 203 (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 Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 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 VOUCHER NO. WARRANT NO. I ALLOWED 20 IN SUM OF oto mom, l r j 0 3 Z- L� ON ACCOUN RIATION FOR Iffa Board Members Po# or INVOICE NO, ACCT #(TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or d Z L /y(p0�bs I (o, y� 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 Slg Cost distribution ledger classification if Title claim paid motor vehicle highway fund