170855 04/16/2009 CITY OF CARMEL, INDIANA VENDOR: 362307 Page 1 of 1
ONE CIVIC SQUARE GEIGER PETERS INC CHECK AMOUNT: $47,221.20
CARMEL, INDIANA 46032 PO BOX 33807
INDIANAPOLIS IN 46203 CHECK NUMBER: 170855
CHECK DATE: 411612009
'DEPARTMENT ACCOUNT PO NUM INVOICE NUMBER AMO DESCRIPTION
902 4460848 02- 08025 47,221.20 4TH GATEWAY /RANGELINE
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APPLICATION AND CERTIFICATE FOR PAYMENT CONSTRUCTION MANAGER -A v TTION PAGE D ISER ED E ONE OF TWO PAGES
AIA DOCUMENT G7021CMa (Instructions on reverse side)
TO (OWNER), Carmel Redevelopment Commission PROJECT: Carmel Gateway Arch APPLICATION NO.: 02 -08025 Distribution to:
w 136th St Rangeline Road PERIODTO: 3/31109 OWNER
CD
CD Carmel IN PROJECT NOS: CONSTRUCTION MANAGE]
VIA (CONSTRUCTION MANAGER): Keystone Construction ARCHITEO -rr
FROM (CONTRACTOR): Geiger Peters, Inc 47 S Pennsylvania St 10th Floor CONTRACT DATE: CONTRACTOR
P O Box 33807 Indianapolis, IN 46204
Indianapolis, Indiana 46203
CO StructmrlSteel
CONTRACTOR APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge. Infor-
Application is made for Payment, as shown below, in connection with the Contract. mation and belief the Work covered by this Application for Payment has been completed
Continuation Sheet, AIA Document G703, is attached. 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 pay
1. ORIGINAL CONTRACT SUM. 47,500.00 ments received from the Owner, and that current payment shown herein is now due.
2. Net change by Change Orders 11,368.00 CO TOR:
3, CONTRACT SUM TO DATE (Line L+ 2)........... 58,868.00 By Date: 3113109
4. TOTAL COMPLETED 8: STORED TO DATE 58,868.00
(Column G on G703) State of: Indiana
Cwty of: Marion
5. RETAINAGE: Smliscnbed and swomtobefore
a. 10 %of Completed Work meths lath dayd March,2009
W (Column D +E on G703) 8 5,886.80 KRISTINE M. GRACE
a b. 10 %of Stored Material NotaryPublI $rata oflndisna
(Column F on G703) [Y. Marion County
Total Rerainage (Line 5a +5b or J My Commission Expires
Total in Column I of G703) 5,886.80 Notary Public: Kristine M Grace Isla Juno 06, 2013
W My Commission expires: 616/2093
6. TOTAL EARNED LESS RETAINAGE
52,961,20
H
(Line 4less Line 5 Total)
ARCHITECT'S CERTIFICATE FOR PAYMENT
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT In accordance with the Contract Documents, based on oa -site observations and the data
(Line 6 from prior Certificate 5,760.00 comprising this application, the Architect certifies to the Owner that to the best of the
Owner's knowledge, information and belief the Work has progressed as indicated, the
quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE. 47,221.20 is entitled to payment of the AMOUNT CERTIFIED.
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un `l
9. BALANCE TO FINISH, INCLUDING RETAINAGE L tZf
AMOUNT CERTIFIED.........
S
CID (Line 3 less Line 6) 5,666,60 (Attach explanation ijamount cerlI. iri1 "�fCW 1 09. o li jo Initial
M oli Jigume on lhWAAMORO the Continuation Sheer iha are changed io
conform to the atRanlcell� led.
r o j �F L C..CODE
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS CONSTRUCTIO AGER
rs. Total changes approved in By: 1 r 3 Date: 0 1
p revious months by Owner S
M Total approved this month S 11,368.00 ARC TECT
p� TOTALS S 11,368.00 $y; r", E _A Di 3 3C Og
NET CHANGES by Chanp Orda 511,368.00
This Certific �e AMOZJti<1S CERTIF D is pay ab a only to the con
rn tractor name erel uan e,
payment and acc�aitce�o payment are without
°o prejudice to an jigRts o un'�aTfil ConEa�t,
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m
M AIA DOCUMENT G7021CMa APPLICATION AND CERTIFICATE FOR PAYMENT CONSTRUCTION MANAGER- ADVISER EDITION
1992 EDITION' 1992 AIA 1992 THE AMERICAN INS ITITTE OF ARCHIIECIS, 1735 NEW YORK AVENUE. N.W., WASHINGTON, G702 /Cma-1992
D.C. 2006 -5292
CONTINUATION SHEET AIA DOCUMENT G703 (nstructioneverse side} PAGE TWO OF TWO PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing APPLICATION NO.-. 02 -08025
Contractor's signed Certification is attached. Geiger Peters APPLICATION DATE: 3/13/09
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 3/31/09
"o Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO:
0
A B C D E F G H I
SCHEDULED WORK COMPLETED MATERIALS TOTAL BALANCE _RETAINAGE
VALUE ROM PREVIOUS THIS PERIOD PRESENTLY COMPLETED (G:C) TO FINISH
ITE DESCRIPTION OF APPLICATION STORED AND STORED (C-G)
NO. WORK ESTIMATED (D +E) (NOT IN TO DATE
COST D OR E) E +F)
I Detailing Shop Drawing 6,400.00 6,400.00 6,400.00 100% 640.00
2 Steel Material Fabrication 23,660.00 23,660.00 23,660.00 100% 2,366.00
3 Miscellaneous Metals 10,540.00 10,540.00- 10,540.00 100% 1,054.00
4 steel Erection 6,900.00 6,900.00 6,900.00 100% 690.00
5 C/O 1 11,368.00 11,368.00 .11,368.00 100% 1,136.80
6
7
a 8
H 9
a 10
a3 11
x 12
13
w 14
15
16
17
18
19
n 20
Cn 21
M 2z
23
24
25
>4
w
M S 58,868.00 6,400.00 52,468.00 S 58,868.00 100% 5
rn
CD AIA DOCUMENT G702 APPLICATION AND CERTIFICATE FOR PAYMENT 1992 EDITION AIA 1992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK
w o AVENUE, N. W., WASHINGTON, D.C. 20006 -5292
w G703 -1992
M
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03/13/2009 09:35 FAX 317 359 9525 GEIGER PETERS 0 004
WAIVER OF LIEN TO DATE
STATE OF Indiana
COUNTY OF Marion SS
TO WHOM IT MAY CONCERN:
WHEREAS the undersigned has been employed by Keystone Construction
to furnish Structural Steel
for the premises knows as Carmel Gateway Arch
of which Carmel Redevelopment Commission is the owner.
THE undersigned, for and in consideration of Forty Seven Thousand Two Hundred Twenty One and 20/100
47,221.20 Dollars, and other good and valuable considerations, the receipt whereof is hereby acknowledged, do(es) hereby
waive and release any and all lien or claim of, or right to, lien, under the statutes of the State of Indiana, relating to mechanics' liens, with respect to
above described premises, and the improvements thereon, and on the material, fixtures, apparatus or machinery furnished, and on the moneys,
funds or other considerations due or to become due from the owner, on account of all labor, services, material, fixtures, apparatus or machinery,
furnished to this date by the undersigned, for the above described premises, including extras
DATE 3113/2009 COMPANY NAME Geiger Peters Inc,
ADDRESS P O Box 33807 Indianapolis, IN 46203
SIGNATURE AND TITLE 1Controller
EXTRAS INCLUDE Bur ARE NOT LIMITED TO CHANGE ORDERS, BOTH ORAL AND WRITTEN, TO THE CONTRACT.
CONTRACTOR'S AFFIDAVIT
STATE OF Indiana
COUNTYOF Marion SS
TO WHOMIT MAY CONCERN:
THE UNDERSIGNED, Debra Burton BEING DULY SWORN, DEPOSES
AND SAYS THAT HE OR SHE IS Controller OF
Geiger Peters Inc. WHO IS THE
CONTRACTOR FURNISHING Structural Steel WORK ON THE BUILDING
LOCATED AT 136th St Rangeline Road
OWNED BY Carmel Redevelopment Commission
That the total amount of the contract including extras* is 58,868.00 on which he or she has received payment of
5,760.00 prior to this payment. That all waivers are true, correct and genuine and delivered unconditionally
and that there is no claim either legal or equitable to defeat the validity of said waivers. That the following are the names and addresses of all
parties who have furnished material or labor, or both, for said work and all parties having contracts or sub contracts for specific portions of said
work or for material entering into the construction thereof and the amount due or to become due to each, and that the items mentioned include all
labor and material required to complete said work according to plans and specifications:
NAMES AND ADDRESSES WHAT FOR C°NIRACTPR]CH AMOUNT THIS
1NQ.ID]NGEXTUS• PAID PAYMENT BALANCE DUE
Geiger Peters Inc. Structural Steel 58,868.00 5,760,00 47,221.20 5,886.80
TOTAL LABOR AND MATERIAL INCLUDING EXTRAS TO COMPLETE 58,868.001 5,760.001 47,221.201 5,886.80
That there are no other contracts for said work outstanding, and that there is nothing due or to become due to any person for material, labor or
other work of any kind done or to be done upon or in connection with said work other than above stated.
DATE 3/13/2009 SIGNATURE:
SUBSCRIBED AND SWORN TO BEFORE ME THIS lath DAY OF March 2006.
Kristine M Grace Resident of M 2rion County M i o eI>�Ol
`EXTRAS INCLUDE BUT ARE NOT LWTED TO CHANGE ORDERS, BOTH ORAL AND WRITTEN, TO THE CONTRACT. KRISTINE M. GRACE
Notary Public, State of Indiana
l Marion County
My Commission Expires
June 06, 2013
03/'13/2009 09:34 FAX 317 359 9525 GEIGER PETERS Z001
Geiger Peters, Inc.
317 359 -9521 a FAX 317 359 -9525
grace(cr�.gpsteel.com
FACSIMILE TRANSMITTAL SHEET
TO: Bruce Stulfer
COMPANY: Keystone Construction
FROM: Kris Grace
DATE: 3/1 3/09
FAX NUMBER: 635 -1100
PHONE NUMBER:
TOTAL NUMBER OF PAGES (including cover): 4
RE: 08 -025 Carmel Gateway Arch
Urgent Review Please Comment Please Reply
Please fax or e-mail your approval.
Thank you
Kris
CONFIDENTIALITY NOTICE: This facsimile message, including any attachments is for the sole use of the intended recipient(s)
and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is
prohibited. If you are not the intended recipient, please contact the sender by phone or by reply facsimile and destroy
all copies of the original message.
761 S. Sherman Drive PO Box 33807 Indianapolis, IN 46203
P.rescribetl 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.
Paye
'y 'f- ,yam Purchase Order No.
Po 6 3 F IY07 Terms
"Z 4 16 2v Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
o2 0 025 �'8 y�22/.2o
E�
Total -7 -2
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.,1
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF
33,:?G'7
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
O2 ,I W25 yy1615 X7 221.2 6 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
2
Signatur
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund