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Home My WebLink About203643 11/09/2011 u, CITY OF CARMEL, INDIANA VENDOR: 363626 Page 1 of 1 ONE CIVIC SQUARE THIENEMAN CONSTRUCTION INC CHECK AMOUNT: $25,698.20 CARMEL, INDIANA 46032 3313 EAST 83RD PLACE •'".run MERRILLVILLE RI 46410 CHECK NUMBER: 203643 CHECK DATE: 1119(2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 659 5023990 25 25,698.20 1050.75 AIA Type Document Application and Certification for Payment Page 1 of 8 TO (OWNER): City of Carmel PROJECT. Carmel Contract 70 APPLICATION NO: 25 DISTRIBUTION 760 3rd Avenue SW 9609 Hazeldell Pk Suite 110 Carmel, IN 46032 PERIOD TO: 9126/2011 TO: _OWNER Carmel, IN 46032. ARCHITECT —CONTRACTOR FROM (CONTRACTOR): Thieneman Construction, Inca VIA (ARCHITECT): Jones Henry, Ltd. ARCHITECTS 3313 East 83rd Place PROJECT NO: SRF WWO92829 01 Merrillville, IN 46410 CONTRACT FOR: City of Carmel WWTP Expansion CONTRACT DATE: 10/7/2009 CONTRACTOR APPLICATION FOR PAYMENT The Undersigned Contractor certifies that to the best of the Contractor's knowledge, information and belief the work covered by this application for Payment has been completed in accordance with the Application is made for Payment, as shown below, in connection with the Contract. Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Continuation Sheet, AIA Type Document is attached. Certificates for Payment were issued and payments received from the owner, and that current payment shown herein is now due. 1. ORIGINAL CONTRACT SUM 5,454,500.00 2. Net Change by Change Orders 304,416.18 CONTRACTOR: hie an Construction, Inc. 31 ast 83rd Place Merrillville, IN 46410 3. CONTRACT SUM TO DATE (Line 1 5,150,083.82 4. TOTAL COMPLETED AND STORED TO DATE 5,150,083.82 By: P Date: 5. RETAINAGE: Jos orris I Project Manager Completed ork State a. 0.49 of \.F'�'` P 25,000.00 f County of: Hamilton b. 0.00 of Stored Material 0.00 Subscribed and Sworn to before me this t —Ua bf 20 Poic 1., o� to Y C ,f sa�,r� Total retainage (Line 5a 5b) Notary Public: COL"I" 25,000:00 u /a M Commission E Y P 1JQ0 J Dc'sfta i 6. TOTAL EARNED LESS RETAINAGE 5,125,083.82 (Line 4 less Line 5 Total) ARCHITECT'S CERTIFICATE FOR PAS' AI� 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT In Accordance with the Contract Documents, based on on -site observations and the data com- (Line 6 from 5,099,385.62 prising the above application, the Architect certifies to owner that to the best of the Architect's P rior Certificate) knowledge, information and belief the Work has p4ogressed as indicated,the quality of the work 8. CURRENT PAYMENT DUE 25,698.20 is in accordance with the Contract Documents, and the Contractor is entitled to payment of the 9. BALANCE TO FINISH, INCLUDING RETAINAGE AMOUNT CERTIFIED. (Line 3 less Line 6) ;25,000.00 AMOUNT CERTIFIED........... i (Attach explanation if amount certified differs from the amount applied. Initial all figures on this CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Application and on the Continuation Shea` that are changed to conform to the amount certified.) Total changes approved in ARCH IT co✓�s r ��zaz l previous months by Owner 11,122.00 -341,236.38 B y: BY: G� Date: f Total approved this Month 25,698.20 0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, Payment and acceptance of payment are without prejudice to any TOTALS 36,820.20 341,236.38 rights of the Owner or Contractor under this Contract. NET CHANGES by Change Order j 304,416.18 Prescribed State Board Accounts ACCOUNTS PAYA�B�..�.,VOUCHER Form No. 301 01 -5 (Rev. 1995) AbDRESS L53 Agrt..l ((-y I Invoice Date Invoice Number Item Amount I hereby certify that the attached invoice(s), or 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 19 Signature Title 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. 19 �*i 1,4 ficer Title Voucher No. Warrant No. ACCOUNTS PAYABLE DETAILED ACCOUNTS SANITATION DEPARTMENT ACCT. CARMEL, INDIANA I d.�ii N� Jvil�� Fa tj 7 3313 V n,. 9L44 Total Amount of Voucher Deductions Amount of Warrant Month of 19 VOUCHER RECORD A No. Collection System Operation Plant Commercial General Undistributed Construction Depreciation Reserve Stock Accounts Merchandise Total Allowed Board Members Filed BOYCE FORMS SYSTEMS 1 -800- 382 -8702 325