205872 01/31/2012 CITY OF CARMEL, INDIANA VENDOR: 365624 Page 1 of 1
ONE CIVIC SQUARE HIS CONSTRUCTORS INC
CARMEL, INDIANA 46032 5150 E 65TH STREET SUITE B CHECK AMOUNT: $8,912.25
INDIANAPOLIS IN 46220 -4817
CHECK NUMBER: 205872
CHECK DATE: 1/31/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
211 R4462300 25806 4 8,912.25 WESTWOOD DRIVE BRIDGE
CONSTRUCTION PROJECT INVOICE
DATE: January 23, 2012
COMPANY NAME: HIS Constructors, LLC
AND ADDRESS 5150 East 65`' Street, Suite B
Indianapolis, Indiana 46220
TELEPHONE NO.: (317)-284-1195 w
FAX NO.: (317)-284-1185
PROJECT NAME: Hamilton County Bridge 289
Westwood Drive over Mitchner Ditch
PROJECT NO.: 11 -08
INVOICE NO.: 4
TOTAL EARNINGS TO DATE: 131,727.04
MINUS 10% RETAINAGE: O 13,172.70
TOTAL EARNED MINUS RETAINAGE: 118,554.34
MINUS PREVIOUS PAYMENTS: 109,642.09
TOTAL AMOUNT DUE: 8,912.25
aL
Dan Greska p
Construction Manager
City of Carmel
APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT G702 PAGE 1 OF 3 PA
TO: City of Carmel PROJECT: Carmel Bridge 289 APPLICATION NO: 4 Distribution to:
One Civic Square PERIOD TO: 11/30/11 FJOWNER
Carmel, IN 46032 PROJECT NOS: #11 -08 J1 ENGINEER
PURCHASE ORDER: n CONTRACTOR
OTHER
FROM: HIS Constructors, Inc VIA: INVOICE DATE: x f2lTJ201'1
5150 E. 65th Street, Suite B
Indianapolis, IN 46220 CONTRACT DATE: 8/3/2011
CONTRACT FOR:
SUBCONTRACTOR'S 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 Contract Documents, that all amounts have been
Application is made for payment, as shown below, in connection with the contract paid by the Contractor for Work for which previous Certificates were issued and payments received from the Owner, and that
Continuation Sheet, AIA Document G702, is attached. current payment shown herein is now due.
1. ORIGINAL CONTRACT SUM 154,800.00 SUBCONTRACTOR: HIS Constructors, Inc
2- Net change by Change Orders (21,152.96)
By: Date: 1/20/2012
3. CONTRACT SUM TO DATE (Line 1 t 2) 133,647.04
State of Indiana
4. TOTAL COMPLETED TO DATE 131,727.04
(Column J on G703) minty of Marion
5. RETAINAGE:
a. 10 of Completed Work 13,172.70 Subscribed and sworn to before
me this 20th day of January, 2012
b. 0 of Stored Material Notary Public:
My Commission a s: 8122120
Total Retainape (Line 5a 5b) 13.1.72.70 SUBCONTRACTORS CERTIFICATE FOR PAYMENT
6. TOTAL EARNED LESS RETAINAGE 118,554.34 In accordance with the Contract Documents, based on on -site observations and the data comprising this application,
(Line 4 less Line 5 Total) the Architect certifies to the Owner that to the best of the Architect's knowledge, information and belief the Work has
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT progressed as indicated, the quality of the Work is in accordance with the Contract Documents, and the Contractor is
(Line 6 from prior Certificate) 109,642.09 entitled to payment of the AMOUNT CERTIFIED.
8. CURRENT PAYMENT DUE 8,912.25
j 9. BALANCE TO FINISH 10. VARIANCE TO CONTRACT AMOUNT CERTIFIED 8,912.25
15, 092.70 21,152.96
(Attach explanation if amount certified differs from the amount applied for. Initial all figures on this Application and
i on the Continuation Sheet that are changed to conform to the amount certified.)
1 i CHANGE ORDER BY SUMMARY ADDITIONS DEDUCTIONS OWNER: CITY OF CARMEL
Total changes approved in
previous months by Owner (21,152,96) By: Date:
Total approved this Month
TOTALS 21,152.96 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, payment and
NET CHANGES by Change Order (21152961 acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contrad.
AIA DOCUMENT 0702 APPLICATION AND CEMIFICATE FOR PAYMENT -1992 EDRION -ILA®- 01992- THE AMERICAN NSTITUTE OF ARCHITECTS, 1733 NEW YORK
1 AVENUE, N.W., WASHINGTON, D.C. 20006 -6292 WARNNOt G702 -1992
•Thb document has been reproduced electroulmilyvft the permicalm cf The Amedcen Ytstlhde of ArcNteda under Lherse 970003 Pftmv a Systems, brc. Reproduction of "is deaummR v,4hout poje,*Wci6e Wennstlon le rot pemdtted. Contact The American institute of AreMects to wMy the cummt "chin of it& document end kense
stah9.
Application and Certificate For Payment page 2
To Owner: CITY OF CARMEL Application No: 4 Date: 12/31111 Period To: 12/31/11
From (Contractor): HIS CONSTRUCTORS, INC. Contractor's Job Number: 110025
Project: CITY OF CARMEL BRID 289 Architect's Project No:
Work Completed Work Completed Completed and Stored To Date
Item Unit Contract Scheduled Previous Application This Period
N umber Description Price Quantity UM Value Quantity Amount Quantity mount
ty Quantity Amount Retention M emo
01
001 CONSTRUCTION ENGINEE 2,400.0000 1.00 LS 2,400.00 100.00% 2,400.00 0.00% 0.00 100.00% 2,400.00 100.0 240.00
RING
002 MOBILIZATION AND DEM 7,800.0000 1.00 LS 7,800.00 100.00% 7,800.00 0.00% 0.00 100.00% 7,800.00 100.0 780.00
OBILIZAMON
003 CLEARING RIGHT OF WAY 5,718.2000 1.00 LS 5,718.20 100.00% 5,718.20 0.00% 0.00 100.00 5,718.20 100.0 571,82
004 TEMPORARY IN-STREAM SILT 1,000.0000 .00 LSU 0.00 .35 350.00 -.35 350.00 .00 0.00 0.0 0.00
BASIN
005 EXCAVATION COMMON 55.0000 138.00 CYS 7,590.00 83.00 4,565,00 55.00 3,025.00' 136.00 7,590.00 100.0 759.00
006 EXCAVATION WATERWAY 45.0000 25.00 CYS 1,125.00 .00 0.00 .00 0.00 .00 0.00 0.0 0.00
007 EXCAVATION FOUNDATI ON 35.0000 52.00 CYS 1,820.00 .00 0.00 52-00 1,820.00 52.00 1,820.00 100.0 18200
UNCLASSIFIED
008 TEMPORARY SILT FENCE 2.7500 .00 LFT 0.00 .00 0.00 .00 0.00 .00 0.00 0,0 0.00
UNDISTRIBUTED
009 AGGREGATE FOR END BE NT 70.0000 25.09 CYS 1,756.30 22.60 1,582.00 2.49 174.30 25.09 1,756.30 100.0 175.63
BACKFILL
010 COMPACTED AGGREGATE 53 30.0000 181.71 TON 5,451.30 .181.71 5,451.30 .00 0.00 181.71 5,451.30 100.0 545.13
BASE
011 HMA SURFACE TYPE A 119.0000 32.10 TON 3,819.90 32.10 3,819.90 .00 0.00 32.10 3,819.90 100.0 381.99
012 HMA INTERMEDIATE TYPE A 106.0000 59.61 TON 6,318.66 59.61 8,318.66 .00 0.00 59.61 6,318.66 100.0 631.87
013 HMA BASE TYPE A 88.0000 65.98 TON 5,804.48 65.98 5,804,48 .00 0.00 85.96 5,804.48 100.0 580.45
014 BENCHMARK 500.0000 1.00 EAC 500.00 1.00 600.00 .00 0.00 1.00 500.00 100.0 50.00
015 BURIED TIMBER GUARDRAIL 1,300.0000 4.00 EAC 5,200.00 4.00 5,200.00 .00 0.00 4.00 5,200.00 100.0 520.00
END SECTION INS
016 TIMBER GUARDRAIL INSTALL 41.0000 96.00 LFT 3,938.00 96.00 3,936.00 .00 0.00 96.00 3,936.00 100.0 393,80
ONLY
017 TIMBER BRIDGE RAIL INSTALL 48.0000 84.00 LFT 4,03200 84.00 4,032.00 .00 0.00 84.00 4,032.00 100.0 40320
ONLY
016 GEOTEXTILES 2.5000 390.00 SYS 875,00 .00 0.00 72.00 180.00 72.00 180.00 18.5 18.0D
019 RIPRAP CLASS 1 24 DEPTH 35.0000 21,02 TON 735.70 61.00 2,136.00 39.98 1,399.30 21.02 735.70 100.0 7357
020 SEED MIXTURE R 47.0000 42.50 LBS 1,997.50 .00 0.00 42.50 1,997.50 42.50 1,997.50 100.0 199.75
021 FERTILIZER 2,100.0000 .05 TON 105.00 .00 0.00 .05 105.00 .05 105.00 100.0 10.50
022 MULCHED SEEDING T 3.0000 .00 SYS 0.00 .00 0.00 .00 0,00 .00 0.00 0,0 0.00
UNDISTRIBUTED
023 TEMPORARY EROSION CO 4.0000 800.00 SYS 3,200.00 .00 0.00 800.00 3,200.00 800.00 3,200.00 100.0 320.00
NTROL BLANKET
024 MOBILIZATION AND DEM 265.0000 1.00 EAC 265.00 1.00 265.00 .00 0.00 1.00 265.00 100.0 26.50
OBILIZATION FOR SEED
025 END BENT DRAIN PIPE 6 13.0000 75.00 LIFT 975.00 75.00 975.00 .00 0.00. 75.00 975.00 100.0 97.50
DIAMETER
026 SAW CUT JOINT 13.0000 40.00 LFT 520.00 40.00 520.00 .00 0.00 40.00 520.00 100.0 52.00
I 027 PILING STEEL H PILES HP 65.0000 312.00 LFT 20,280.00 312.00 20,280.00 .00 0 312.00 20,280.00 100.0 2,028.00
12X53
i
Application and Certificate For Payment page 3
To Owner: CITY OF CARMEL Application No: 4 Date: 12/31/11 Period To: 12/31/11
From (Contractor): HIS CONSTRUCTORS, INC. Contractor's Job Number: 110025
Project: CITY OF CARMEL BRID 289 Architect's Project No:
Work Completed Work Completed Completed and Stored To Date
Previous Appilcatlon Thls Period
I[em Unit Contract Scheduled
Number Description Price Quantity UM Value Quantity Amount Quantity Amount Quantity Amount Retention Memo
028 EPDXY COATED REINFOR 12000 4140.00 LBS 4,968.00 4140.00 4,968.00 .00 0.00 4140.00 4,968.00 100.0 496.80
CING STEEL
029 CONCRETE A SUBSTRU 950.0000 21.20 CYS 20,140.00 21.20 20,140.00 .00 0.00 21.20 20,140.00 100.0 2,014.00
CTURE
030 STRUCTURAL MEMBRANE 30.0000 150.00 SYS 4,500.00 150.00 4,500.00 .00 0.00 150.00 4,500.00 100.0 450.00
WATERPROOFING
031 WS 17 X4'-0 CONCRETE 7.0000 924.00 SFT 6,468.00 924.00 6,468.00 .00 0.00 924.00 6,469.00 100.0 646.80
BOX BEAMS INSTA
032 SURFACE SEAL 1,150.0000 1.00 LS 1,150.00 0.00% 0.00 100.00% 1,150.00 100.00% 1,150.00 100.0 115.00
i
033 FIELD TILE UNDISTRI BUTED 15.0000 .00 LFT 0.00 .00 0.00 .00 0.00 .00 0.00 0.0 0.00
034 CONSTRUCTION SIGN T YPE 130.0000 8.00 EAC 1,040.00 8.00 1,040.00 .00 0.00 8.00 1,040.00 100.0 104.00
A
035 CONSTRUCTION SIGN TYPE 70.0000 2.00 EAC 140.00 2.00 140.00 .00 0.00 2.00 140.00 100.0 14.00
B
036 STANDARD BARRICADE TYPE 13.0000 40.00 LFT 624.00 48.00 624.00 .00 0.00 48.00 624.00 100.0 62.40
IIIA
037 STANDARD BARRICADE TYPE 14.0000 48.00 LFT 672.00 48.00 672.00 .00 0.00 48.00 67200 100.0 67.20
IIIB
038 DETOUR ROUTE MARKER 140.0000 7.00 EAC 960.00 7.00 980.00 .00 0.00 7.00 980.00 100.0 98.00
ASSEMBLY
D39 ROAD CLOSURE SIGN AS 160.0000 4.00 EAC 640.00 4.00 640.00 .00 0.00 4.00 640.00 100.0 63.99
SEMBLY
Boo LOAD AND TRANS WOOD RAIL 0.0000 1.00 LS 0.01 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.0 0.00
PIECES
900 OVERHEAD 0.0000 1.00 LS 0.01 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.0 0.00
Total 133,647.08 121,824.54 9,902.50 131,727.04 13,172.70
Application Total 133,647.06 121,824.54 9,902.50 131,727.04 13,172.70
f
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
HIS Constructors, LLC
Purchase Order No.
5150 East 65th Street Suite B
Terms
Indianapolis, IN 46220
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
0112311-2-- 4 ed BF eveF Mitchner D Construction $8,912.25
Total
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in acodfdance
with IC 5- 11- 10 -1.6.
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
HIS Constructors, IN SUM OF
5150 East 65th Street Suite B
Indianapolis, IN 46220
$8,9 12.25
ON ACCOUNT OF APPROPRIATION FOR
Department of Engineering
Board Members
PO# or INVOICE NO. ACCT /TITLE AMOUNT
DEPT. 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
25806 4 211 -"62300 $8,912.25 which charge is made were ordered and
received except
20
Jdr Signature
ct e
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund