HomeMy WebLinkAbout176807 09/02/2009 CITY OF CARMEL, INDIANA VENDOR: 00352446 Page 1 of 1
ONE CIVIC SQUARE INFRASTRUCTURE CONTRACTORS, INC 6ECK AMOUNT: $5,728.96
CARMEL, INDIANA 46032 16100ALLISONVILLE ROAD
NOBLESVILLEIN 46060 CHECK NUMBER: 176807
CHECK DATE: 9/2/2009
DEPARTMEN ACCOUNT PO NUMBER INVOICE NUMBER AM OUNT DES
601 5023990 W08911 4094 5,728.96 CONSTRUTION
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Page 1
c b PAYMENT APPLICATION
TO: City of Carmel PROJECT Jumper Lane APPLICATION 2 Distribution to:
Carmel Utilities 3450 W. 131st Street NAME AND Water
Westfield, IN 46074
LOCATION: PERIOD THRU: 05/06/2009 E] OWNER
PROJECT #s: ARCHITECT
Attn: Accounts Payable
FROM: Infrastructure Contractors, Inc. ARCHITECT: DATE OF CONTRACT: 04/23/2009 CONTRACTOR
16100 Allisonville Road
Noblesville, IN 46060 El
FOR: Jumper Lane
CONTRACTOR'S SUMMARY OF WORK Contractor's signature below is his assurance: to Owner, concerning the payment herein applied for,
that: (1) the Work has been performed as required in the Contract Documents, (2) all sums
Application is made for payment as shown below. previously paid to Contractor under the Contract have been used to pay Contractor's costs for labor,
Continuation Page is attached. materials and other obligations under the Contract for Work previously paid for, and (3) Contractor is
legally entitled to this pa ment.
1. CONTRACT AMOUNT 57,291. 8 8 CONTRACTOR: frastructure Co ra o s, Inc.
2. SUM OF ALL CHANGE ORDERS 0 00 By: Date: 05/06/2009
3. CURRENT CONTRACT AMOUNT (Line 1 2) 57,291.88 Jam Johnson
4. TOTAL COMPLETED AND STORED $57, 291.88 State of: �iaa
(Column G on Continuation Page) County of: Hamilton
5. RETAINAGE: Subscribed and sworn to before
a. 0.00% of Completed Work $0.00 me this 6th day of May 2009
(Columns D E on Continuation Page)
b. 0.00% of Material Stored $0.00 Notary Public: Melissa C. Lawson
(Column F on Continuation Page)
My Commission Expires: September 6, 2015
Total Retainage (Line 5a 5b or
Column I on Continuation Page) $0.00 ARCHITECT'S CERTIFICATION
6. TOTAL COMPLETED AND STORED LESS RETAINAGE $57,291.88 Architect's signature below is his assurance to Owner, concerning the payment herein applied for,
(Line 4 minus Line 5 Total) that: (1) Architect has inspected the Work represented by this Application, (2) such Work has been
7. LESS PREVIOUS PAYMENT APPLICATIONS $51,562.92 completed to the extent indicated in this Application, and the quality of workmanship and materials
conforms with the Contract Documents, (3) This Application for Payment accurately states the amount
of Work completed and payment due therefor, and (4) Architect knows of no reason why payment
8. PAYMENT DUE $5,728.96 should not be made.
9. BALANCE TO COMPLETION CERTIFIED AMOUNT
(Line 3 minus Line 6) $0.00 (If the certified amount is different from the payment due, you should attach an explanation.
Initial all the figures that are changed to match the certified amount.)
SUMMARY OF CHANGE ORDERS ADDITI DEDUCTIONS
Total changes approved in ARCHITECT:
previous months $0.00 $0.00
By: Date:
Total approved this month $0.00 $0.00
TOTALS $0.00 $0.00 Neither this Application nor payment applied for herein is assignable or negotiable. Payment shall
be made only to Contractor, and is without prejudice to any rights of Owner or Contractor under
NET CHANGES $0.00 the Contract Documents or otherwise.
PAYMENT APPLICATION QSS, INC. DOCUMENT
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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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
00352446
INFRASTRUCTURE CONTRACTORS, INC. Purchase Order No.
PO BOX 1791 Terms
NOBLESVILLE, IN 46061 Due Date 8/19/2009
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
8/19/2009 4094 $5,728.96
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
F I q 'K
Date Offi
VOUCHER 092858 WARRANT ALLOWED
00352446 IN SUM OF
INFRASTRUCTURE CONTRACTORS, I
PO BOX 1791
NOBLESVILLE, IN 46061
1' Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
4094 01- 1050 -97 $5,728.96
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Voucher Total $5,728.96
Cost distribution ledger classification if
claim paid under vehicle highway fund