160073 05/28/2008 CITY OF CARMEL, INDIANA VENDOR: 356934 Page 1 of 1
ONE CIVIC SQUARE SIGNATURE CONSTRUCTION LLC
f CHECK AMOUNT: $145,217.82
AVE sw �zo 3R
CARMEL, INDIANA 4603 CARMEL IN 46032 CHECK NUMBER: 160073
CHECK DATE: 5/2812008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AM OUNT DESCRI
902 4460805 8 145,217.82 RETAIL SITE ##5
i
PARTIAL
Payment to Follow
AFFIDAVIT AND WAIVED 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 513 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 one
hundred forty -five thousand two hundred seventeen
dollars and eighty -two cents 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
m Koontz
President
Subscribed and sworn to before me this: 0
Notary Public:
LINDA BUCHANAN
Hancock County
My Commission Expires
APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE ONE OF 2 PAGES
TO OWNER Carmel Redevelopment Commissic PROJECT: Parcel 5B APPLICATION NO Draw Number 5 Distribution to.
One Civic Square Phase I Carmel City Center Signature costs =OWNER
Carmel, Indiana 46032 Motor Court =ARCHITECT
PERIOD TO: 04/2112008 CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design
Signature Construction LLC
720 3rd Avenue SW PROJECT NOS: CSO Project 21010
Carmel, Indiana 46032
CONTRACT FOR: CONTRACT DATE 09/07/2007
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 Document 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 from the Owner, and that current payment shown herein is now due. �iNDA 13UCHANAN
NOTY Hancock County
I. ORIGINAL CONTRACT SUM 2,841,863.00 -:q'• My Commission E iles
2. Net change by Change Orders 0.00 CONTRACTOR: AugU5120, 201
3. CONTRACT SUM TO DATE (Line 1 t 2) S 2,841,863.00
4. TOTAL COMPLETED STORED TO S 1,958,667.33 /r
B Date: y LS o
5. RETAINAGE: Tom K tz President A;PAIL,
a. 0.099 ofCompleted Work 194,256.73 Subscribed d swom to before me this 25 day of Febtn:ep. 2097-
(Column D E on G703)
b. of Stored Material S
(Column F on G703)
Total Retainage (Lines 5a 5b or
Total in Column I of G703) 19 4,256.73 TffCMTEr= ME FOR PAYMENT
6. TOTAL EARNED LESS RETAINAGE 1,764,410.59 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) 1,619,192.77 the quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE 145,217.82 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE 1,077,452.41 Z17.�
(Line 3 less Line 6) AMOUNT CERTIFIED Z
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach expla ron if ar tint certifr rffers from the amounl applied. /nilial all figures on this
Total changes approved Applicario and onrhe ominua n eel I re changed to conform wish the amounl cert fed.)
in previous months by Owner ARCH[ CT:
Total approved this Month By Date: ¢V3/f 0�
TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
tbntraetor named herein. 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 CERTTICATION FOR PAYMENT 1992 EDITION AIA ®1992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE.. N.W., WASHINGTON, DC 200W -S292
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
To: From: Project: Application No.: 8
Carmel Redevelopment Commission Signature Construction LLC Parcel 5B Application Date: 4/21108
One Civic Square 720 3rd Avenue S.W. Phase I Carmel city center Period To: 4/21/08
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 E) (D +E +F) (C -G)
101 General Requirement 932,109.09 84,549.82 2,642.18 0.00 67,192.00 66% 44,917.09 8,719.20
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 1,548,709.00 92,028-60 0.00 1, 640, 737.60 76% 529,352.40 164,073.76
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 4,000.00 12 ,100.00 0.00 16 ,100.00 24% 52,330.00 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 61,650.91 1 14,311.82 1 0.00 1 75, 962.73 1 69%1 34,128.18 1 7,59627
2,841,863,00 1 1,837,584.73 1 121,082.60 0.00 1 1,958,667.33 1 69% 883,195.67 1 194,256.73
Prescribed by Slate 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 service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
�r.y�.��,.�� Co..s•F,����o„ fit' C_ Purchase Order No.
72o 3•pc 4"A ..c w Terms
C r• Ito 1 1 c{ &es Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
4/7r P4 let SQ >l 7 t 7, 8L
Total (y5 717, $Z
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
VULICHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF
Zo 3...l Arc Sw C�..•, TN
4(dalm
Z 17 $Z
ON ACCOUNT OF APPROPRIATION FOR
90z/ qy &okor
Board Members
Po# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
qaZ f�PPL 4q&,agar l 7(7. 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
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund