HomeMy WebLinkAbout167456 12/23/2008 CITY OF CARMEL, INDIANA VENDOR: 00350511 Page 1 of 1
ONE CIVIC SQUARE SMOCK FANSLER CORP
0 CHECK AMOUNT: $7,959.82
CARMEL, INDIANA 46032 2910 W MINNESOTA ST
INDIANAPOLIS IN 46241 CHECK NUMBER: 167456
CHECK DATE: 12/23/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER A DESCRIPTION
902 4460848 2452 7,959.82 4TH GATEWAY /RANGELINE
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REQUEST FOR PAYMENT
From: Smock Fansler Corporation To: CITY OF CARMEL Invoice: 2452
2910 W. Minnesota Street LES OLDS, DIRECTOR OF CRC Draw: APP00001
Indianapolis, IN 46241 -4541 ONE CIVIC SQUARE Invoice date: 11/20/2008
CARMEL, IN 46032 Period ending date: 11/30/2008
Contract For:
Request for payment:
Original contract amount $71,675.00
Approved changes $0.00 Project: 08098
Revised contract amount $71,675.00 CARMEL PARCEL 48. GATEWAY ARCH
Contract completed to date $8,844.25 Contract date:
Add -ons to date $0.00
Taxes to date $0.00
Architect:
Less retainage $884.43
Total completed less retainage $7,959.82 Scope:
Less previous requests $0.00
Current request for payment $7,959.82
Current billing $8,844.25
Current additional charges $0.00
Current tax $0.00 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS
Less current retainage $884.43 Changes approved in previous
Current amount due $7,959.82 Months by Owner
Total approved this Month
Remaining contract to bill $63,715.18 TOTAL
NET CHANGES by Change Order
I hereby certify that the work performed and the materials supplied to date, as shown on the above represent the actual value of the accomplishment under the terms of the
Contract (and all authorized changes thereof) between the undersigned and the CITY OF CARMEL relating to the above referenced project. I also certify that the contractor has �o PRY II P I e /Oi,,�
paid all amounts previously billed and paid by the owner. �0 X/
CONTRACTOR: Smock Fansler Corporation State Of INDIANA County Of MORGAN
By: s� Subscribed and sworn to before me this 7d._ day of Ajcia SEAL
Date: Notary Public
My commission expires: %,,,�sTgT� ....•O�P�.P���`�
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REQUEST FOR PAYMENT DETAIL
Project: 08098 CARMEL PARCEL 48, GATEWAY AR Invoice: 2452 Draw: APP00001 Period Ending Date: 11/30/2008 Detail Page 2 of 2 Pages
Item ID Description Total Previously Work Presently Completed Balance Retainage
Contract Completed Completed Stored And Stored Comp To Balance
Amount Work This Materials To Date Finish
Period
001 MOBILIZATION 5,000.00 2,500.00 2,500.00 50.00 2,500.00 250.00
002 CONCRETE 57,675.00 6,344.25 6,344.25 11.00 51,330.75 634.43
003 PAINT 4,000.00 4,000.00
004 LANDSCAPE PAVERS 5,000.00 5,000.00
Totals 1 2,500.00 6,344.25 8,844.25 12.34 J 62,830.75 884.43
AFFIDAVIT AND WAIVER OF LIEN
Final [X] Partial [X] Payment to Follow
State of Indiana
County of Marion
T.M. Fansler, being duly sworn states that he is the C.E.O. of SMOCK FANSLER CORPORATION
having contracted with: City of Carmel to furnish certain labor, materials, and /or services as follows:
Misc. Construction for a project known as: SFC #08 -098 Carmel Parcel 48 Gateway Arch 4
located at Carmel, Indiana and does hereby state on behalf of the aforementioned contractor:
(PARTIAL WAIVER) that there is due from the owner the sum of:
Sever. Thousand Nine Hundred Fifty Nine Dollars and 82/100
receipt of which is hereby acknowledged; or
[X] the payment of which has been promised as the sole corsideration of this Affidavit and Partial Waiver of
Lien which is given solely with respect to said amount, and which waiver shall be effective only upon
receipt of payment thereof by the undersigned;
(FINAL WAIVER) that the final balance due from the owner is the sum of $0.00
receipt of which is hereby acknowledged; or
the payment of which has been promised as the sole consideration of this Affidavit and Final Waiver of
Lien which shall become effective upon receipt of srch 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,
Materials, and /or Services, furnished by the undersigned thereto, subject to limitations or conditions
expressed herein, if any; and further certifies that no other party has any claim or right to a lien on
account of any work performed, materials, or services furnished to the undersigned for said project, and
within the scope of this affidavit and waiver
SMOCK FANSLER CORP. By 'C/� ®l�I. i Title C.E.O.
T.M. Fansler
WITNESS MY HAND AND NOTARIAL SEAL, this 20` day of November 2008. ?`�pt�
Melissa J. Bish p Nota Public
A
My commission expires 11/30/08 Residing in Morgan County 9T Np
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AC CERTIFICATE OF LIABILITY INSUR OP ID C DATE(MM /DD/YYYY)
INDIS -6 11120108
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATtON
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Connolly Ford Leppert, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Post Office Box 441099 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Indianapolis IN 46244 -1099
Phone:317- 236 -6161 Fax:317- 236 -614 INSURERS A FFORDING COVE NAIC#
INSURED I NSURER A: Amerisur Companies 19488
INSURER B: Fire n- s Fund Xnsuraace C os 218
Indiana Steel Fabricating, Inc INSURER C:
Mr. Steve Dowden
4545 Bradbury INSURER D:
Indianapolis IN 46241 -5210
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS A14D CONDITIONS OF SUCH
POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
fNSRAOD'Li POLICY EFFECTIVE jPOLfCYEXPIRATIOhf
LTR 1NSRD TYPE OF INSURANCE POLICY NUMBER DATE MMIDDIYY I DATE MM /DDIYY LIMITS
I j GENERAL LIABILITY EACH OCCURRENCE 0 0 0, 0 0 0
DATJIAGET6RET4TE[)
A j X i X COMMERCIAL GENERAL LIABILITY CPP 2 0 0 7 6 3 4 03/01/08 1 03/01/09
PREMISES (Ea oc curence) s 100, 000
CLAIMS MADE OCCUR I i MED EXP (A on e per s 5,000
X CG7 04 8 AI End BROAD FORM PD PERSONAL 8 ADV INJURY 1,000,000
Xx ,l Per Proj Agg XCU I GENERAL AGGREGATE S2, 0 00,000
GENT AGGREGATE LIMIT APPLIES PER: PROD COMP /OP AGG s 2 0 0 0 0 0 0
h� POLICY X PRO- I
JE o T LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT i 31,000,000
A X ANY AUTO CA2007633 03/01/08 03/01/09 (Ea accident)
ALL OWNED AUTOS j
-I BODILY INJURY s
I SCHEDULED AUTOS (Per person)
i
X i HIRED AUTOS
BODILY INJURY
X NON -OWNED AUTOS (Per accident) s
Primary and PROPERTY DAMAGE
Nan Contributory I (Per accident)
GARAGE LIABILITY AUTO ONLY EA ACCIDENT S
ANY AUTO EA ACC s
OTHER THAN
AUTO ONLY:
AGG S
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE 1 $7,00 0,000
B X OCCUR CLAIMSMADE SUO 000 08570773 j 03/01/08 03/01/09 AGGRE s 7, 000, 0 00
I
IF
DEDUCTIBLE
OIX RETENTION S10,000
15
i
WORKERS COMPENSATION AND I i X TORY LIld4TS J EP. I
I EMPLOYERS' LIABILITY
A ;ANY PROPRIETORIPARTNEWEXECUTIVE WC2 007 6 3 6 03/01/08 0 3/ 0 1 0 9 E.L. EACH ACCID s 1 0 0 0, 0 0 0
OFFICER/MEMBER EXCLUDED? I I E.L. DIS EA EM P L OYEE 5 1,000, 00 0
IS yes, describe under r
SPECIAL PROVISIONS below E.L. DISEASE POLICY UNLIT S 1,000, 0 0 0
OTHER I
A Transportation CPP2007634 03/01/08 03/01/091 EA Truck 120,000
i Ded. 2,000
DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Project: Carmel Gateway Site 4 Job No. 0 -8098
Coverage is provided for lot reinforcing steel stored at the Indiana Steel
Fabricating yard.
Smock Fansler Corporation is an Additional Insured as respect General
Liability for the above project.
CERTIFICATE HOLDER CANCELLATION
SMOCKFA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
Smock Fansler Corporation IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
2910 West Minnesota Street
Indianapolis IN 46241 -4541 REPRESENTATIVES.
AUTHORIZ7�E IJ PTATIVE
ACORD 25 (2001/08) ACORD CORPORATION 19II£
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 /l
�m (AY_ FQ (I's )`(1] Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
II 0-09 a�5 1 r zls
Total q j c f 7-
1 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
VOU ,-HER NO. WARRANT NO.
ALLOWED 20
Sm or)C tn In 3 tj-f ro IN SUM OF
o7gl �J.
9�� 7z-
ON ACCOUN TION FOR
q0 7
Board Members
Po# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
�D Z L/G�p0kLI Z 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
C Ig `�7 Ce
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund