175667 08/06/2009 CITY OF CARMEL, INDIANA VENDOR: 356511 Page 1 of 1
ONE CIVIC SQUARE DAWSON INC
s' CARMEL, INDIANA 46032 6221 S HARDING ST CHECK AMOUNT: $22,883.60
INDIANAPOLIS IN 46217 CHECK NUMBER: 175667
CHECK DATE: 8/6/2009
DEPA RTMENT ACCOUNT P O NUMBER INVOICE NUM AMOUN DESCRIPTION
902. 4460805 10 22,883.60 RETAIL SITE #5
APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT G702 PAGE ONE OF PAGES
TO OWNER: Carmel Redevelopment Commission PROJECT: APPLICATION NO: 0010 Distribution to:
One Civic Square Carmel. Parcel 5 PERIOD TO: 6/30/2009 OWNER
Carmel, IN 46032
PROJECT NOS.: ARCHITECT
FROM CONTRACTOR: Dawson Incorporated Contractor's Project No. 250007 CONTRACTOR
6221 S. Harding Street ARCHITECT: Shuck Corporation
Indianapolis, IN 46217 3050 South Harding CONTRACT DATE: 6/23/2005
Indianapolis, IN 46217
CONTRACT FOR:
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best ofthe Contractors knowledge, information
and belief the Work covered by this application for Payment has been completed in accordance
Application is made for payment, as shown below, in connection with the contract. with the Contract Documents, that all amounts have been paid by the Contractor
Continuation Sheet, AIA Document G703, is attached. for Work for which previous Certificates for Payment were issued and payment received
1. ORIGINAL CONTRACT SUM S392.700.00 from the Owner, and that current payment shown herein is now due.
CONTRACTOR: Dawson Incorporated
2. Net change by Change Orders $34,268.00
B Date: 6/10/2009
3. CONTRACT SUM TO DATE (Line I ±2) $426,968.00
4. TOTAL COMPLETED STORED TO DATE $426,968.00 State of INDIANA
(Column G on G703) County of: MARION
5. RETAINAGE: Subscribed and sworn to before
a. 0 of Completed Work $0.00 me this 6/10/20 9
(Columns D E on G703)
b. 0 of stored Materiat $0.00 Notary Publi
(Columns F on 6703) My C expires: 7/14/2009
Total Total in Coll Columns (Line a G70 or $0.0
ARCHITECT'S CERTIFICATE FOR PAYMENT
Total in Columns I on G703)
6. TOTAL EARNED LESS RETAINAGE $426,968.00 In accordance with the Contract Documents, based on on -site observations and the data
(Line 4 less Line 5 Total) comprising this application, the Architect certifies to the Owner that to the best of the
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT Architect's knowledge, information and belief the Work has progressed as indicated, the
(Line 6 f orn prior Certificate) 404,084.40 quality of the Work is in accordance with the Contract Documents, and the Contractor
is entitled to payment of the AMOUNT CERTIFIED.
8. CURRENT PAYMENT DUE $22,883.601
9. BALANCE TO FINISH, INCLUDING RETAINAGE AMOUNT CERTIFIED
(Line 3 less Line 6) W00 (Attach explanation if amount certified differs from the amount applied far. Initial
all figures on this Ap ation and on the Continuation Sheet that are changed to
C HANGE ORDER SUMMARY ADDITIONS DEDUCTIONS conform to the a ounI ertified
Total changes approved in
ARCHITECT:
p revious months by Owner $34,268.00 $0.00 By: Date: C- 00 91
Total app roved this Month $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
TOTALS $34 $0.00 Contractor named herein. Issuance, payment and acceptance of payment are without
NET CHANGES b Change Order $34, prejudice to any rights of the Owner or Contractor under this Contract.
J/ AIA DOCUMENT G7132 APPLICATION AND CERTIFICATE FOR PAYMENT. 1992 EDITION AIAV. (c1992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK G702.1992
AVENUE, N.W., WASHINGTON, D.C. 20006 -5292 WARNING: Unlicensed photocopying violates U.S. copyright laws and will subject the violator to legal prosecution.
_"is docurnt has been reproduced electronically vnth the permission of The American Institute of Architects ender L:,. 97003 to Primavera Systems, 1— Reproduction of this document vdthout preiect- specific information is nat permitted.
Contact The American t"titute of Architects to verify the current version of this document and license stLms."
CONTINUATION SHEET AIA DOCUMENT G703 PAGE I OF I PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 0010
containing Contractor's signed Certification, is attached, APPLICATION DATE:
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 6/30/2009
Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO.:
A B C D E F G H I
WORK COMPLETED MATERIALS TOTAL BALANCE
ITEM SCHEDULED PRESENTLY COMPLETED RETAINAGE
DESCRIPTION OF WORK FROM PREVIOUS TO
STORED AND STORED TO FINISH
NO. VALUE APPLICATION THIS PERIOD IF VARIABLE)
(D E) (NOT D OR E) DATE (D +E +F) (O -C) (C G)
000000001 SANITARY SEWER
000000002 Labor $66,256.00 $65,593.44 $662.56 $0.00 $66,256.00 100.000 $0.00
000000003 Material $95,344.00 $94,390.56 $953.44 $0.00 $95,344.00 100.000 $0.00
000000005 MONON TRAIL
000000006 Asphalt $23,000.00 $23,000.00 $0.00 $0.00 $23,000.00 100.000 $0.00
000000007 Labor $27,400.00 $27,400.00 $0.00 $0.00 $27,400.00 100.000 $0.00
D00000008 Material $29,900.00 $29,900.00 $0.00 $0.00 $29,900.00 100.000 $0.00
000000010 EXISTING DITCH
000000011 Labor $3,900.00 $3,900.00 $0.00 $0.00 $3,900.00 100.000 $0.00
000000012 Material $6,900.00 $6,900.00 $0.00 $0.00 $6,900.00 100.000 $0.00
000000014 STORM SEWER
000000015 Labor $51,800.00 $51,800.00 $0.00 $0.00 $51,800.00 100.000 $0.00
OOOO00016 Material $88,200.00 $88,200.00 $0.00 $0.00 $88,200.00 100.000 $0.00
000000019 I Change Order No. 1 $34,268.00 $34,268.00 1 $0.00 1 $0.00 I $34,268.00 100.000 $0.00
TOTAL.. $426,968.09 $425,352.00 $1,616.0 $O.Od $426,968.0 100.00 %1 $0.01
AIA DOCUMENT G703• APPLICATION AND CERTIFICATE FOR PAYMENT 1992 EDITION AIAQJ• 01992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK 'G703 -1992
AVENUE, N.W., WASHINGTON, D.C. 20006 -5292 WARNING: Unlicensed photocopying violates U.S. copyright laws and will subject the violator to legal prosecution.
/ate. "This document has been Inc. Re repmduc d electronically with the permission cf The American Institute of Architects under License 97003 to Primavera systems, f document h
to verifv the rumen, version of this document angrlicense status." y pfO duction o this oc without p.ej�i(ic information is not permided. Contact The American institute of Architects
PARTIAL WAVIER OF LIEN
STATE OF INDIANA
SS:
COUNTY OF MARION
KNOW ALL MEN BY THESE PRESENTS, That the undersigned:
Dawson Incorporated
for and in consideration of: APPLICATION NO: 0010 PERIOD TO: 6/30/2009
for payment in the amount of: $22,883.60
does upon receipt of said payment hereby waive, release and surrender any and all liens or claims or rights
to lien, for labor, material and/or services, and further certifies that no other party has any claim or right to
a lien on account of any work performed or material furnished to the undersigned for said project situated
in the County of Marion, State of Indiana, described as follows:
PROJECT: Carmel Parcel 5
PROJECT NO:
ARCHITECT: Shuck Corporation
CONTRACT:
Dawson Incorporated
CONTRACTOR
Date: 6/10/2009
B
State of INDIANA
County of: MARION
Subscribed and sworn to before me on: 6/10/2009
Notary Public: f
My Commission expires: 7/14/2009
Prescribed by State 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
1/y�vsoy Z��oroarf°� Purchase Order No.
62Z/ S'. Terms
/G�9 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
2 SY3 60'
Total 2 F 3 -�D
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
IN SUM OF
2
ON ACCOUNT OF APPROPRIATION FOR
i'a��y�Ga�yG.s
Board Members
PO# or INVOICE NO, ACCT #fTITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
4W6 F-D 22- MZ0 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 Gg
U
Signature
Director of Operations
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund