162982 08/20/2008 I
CITY OF CARMEL, INDIANA VENDOR: 356934 Page 1 of 1
ONE CIVIC SQUARE SIGNATURE CONSTRUCTION LLC
CHECK AMOUNT: $147,147.38
CARMEL, INDIANA 46032 720 3RD AVE SW
CARMEL IN 46032 CHECK NUMBER: 162982
ON
CHECK DATE: 8/20/2008
D ACCOUNT PO NUMBER INVOI NUMBER AMOU DESCRIPTION
902 4460805 147,147.38 RETAIL SITE #5
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 CAR -MEL, IN and owned by Carmel Redevelopment
Commission and does further state:
PARTIAL WAIVER: that the balance due from the owner is the sum of one
hundred forty seven thousand one hundred forty seven
dollars and thirty -eight cents (147,147.38) 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
f
1pin Koontz
President
Subscribed and sworn to before me this:
Notary Public:
APPLICATION AND CERTIFICATION FOR PAYMENT .41A D OCUYfENT G 702 PAGE ONE OF 2 PAGES
TO OWNER Cannel Redevelopment Colnmissic PROJECT: Parcel 513 APPLICATION NO Draw Number 12 Distribution to:
One Civic Square Phase I Carmel City Center Signature costs =OWNER
Carmel, Indiana 46032 Motor Court ARCHITECT
PERIODTO0 8/112008 HCONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design
Signature Construction LLC
720 3rd Avenue S.W. PROJECT NOS: CSO Project 2 10 10
Carmel, Indiana 46032
CONTRACT FO R: CONTRACT DATE 9/7/2007
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best ofthe Contractor's knowledge,
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 Docmnent G703, 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 fi'oln 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 S 0.00 CONTRACTOR:
3. CONTRACT SUM TO DATE (Line I t 2) 2 1,863 00
4. TOTAL COMPLETED C STORED 'f0 2,536,008.00 p
By: Date: 7 1 27- 0 8)
5_ RETAINAGE: 'Tom K Liz President
a. 0.099 of Completed Work 250.800.80 Su scribe and sworn to before me this 3th day of July, 2007
(Column D+ E on G703)
b. of Stored Material
(Column F on G703)
Total Retainage (Lines 5a 5b or
Total in Column 1 ofG703) 250,8 00.80 CERTIFIC
6. TOTAL EARNED LESS RETAINAGE 2,285,207.20 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 beliefthe Work has progressed as indicated,
PAYMENT (Line 6 from prior Cerificate) S 2,138 059.82 the quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE 147,147.38 is entitled to paymein of the AMOUNT CERTIFIED.
9, BALANCE TO FINISH, INCLUDING RETAINAGE 556,655.80
(Line 3less Line 6) AMOUNT CERTIFIED S AU 0 M
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS e ana on ifmnounr certified d�ers from the amount applied InWai all figures' on this
Total changes approved Applic ton m onthe _5n nuati Sheer that or, changed to co forut a ah the amount certified.)
in previous months by Owner ARC ITEC
Total approved this Month By: Date: 7 3f M
TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to t
Contractor named herein. Issuance, payment and acceptance of payTnent 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 01992 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 2of2
To: From: Project: Application No.: 12
Carmel Redevelopment Commission Signature Construction LLC Parcel 5B Application Date: 811108
One Civic Square 720 3rd Avenue S.W. Phase I Carmel city center Period To: 811108
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 To If
Description of Work Value Application This Period (Not in To Date (G /C) Finish Variable
D or (D +E +F) (C -G)
101 General Requirement 132,109.09 105,687.27 11,889.82 0.00 117,577.09 89% 14,532.00 11,757.71
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 2,016,275.00 137,500.00 0.00 2,153,775.00 99% 16,315.00 215,377.50
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 23,230.00 4,770.00 0.00 28,000.00 41% 40,430.00 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 1 89,173.641 8,807.27 1 0.00 1 97,960.91 1 89%1 12,110.00 9,798.09
2,841,863.00 1 2,373,040.91 162,967.09 0.00 1 2,536,008.00 89% 305,855.00 250,800.80
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (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.
7 Terms
G lrl.e ,v 4 fe o 3 2 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
zz o Na P,.«i s8 IW7 1y�. 3
Total 4 r 114 -7. 3
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.
ALLOWED 20
sr n a.�vre CC,elj ,�G�� LLC IN SUM OF
'7 ZG 3 A Ve SW
I N y�
L4-7 14'7
ON ACCOUNT OF APPROR N FOR
t )C)
Ll
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
q c 2 N A 4 Os 147 3$ 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 OF
Signature
GC Q C F c e
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund