180100 12/08/2009 CITY OF CARMEL, INDIANA VENDOR: 362310 Page 1 of 1
ONE CIVIC SQUARE HAGERMAN CONSTRUCTION CORP
CARMEL, INDIANA 46032 CHECK AMOUNT: $23,012.10
i�
7930 CASTLE WAY DRIVE
INDIANAPOLIS IN 46250 CHECK NUMBER: 180100
CHECK DATE: 12/812009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOU DESCRIPTION
902 4460867 9321 23,012.10 INDIANA DESIGN CENTER
r
APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT G702 PAGEONMOF PAGES
TO OWNER Carmel Redevelopment Conunission PROJECT: Parcel 67 Streetscape APPLICATION NO: B0006 Distribution to:
City of Carmel HCC Job #2691 PERIOD TO: 4/25/2009 OWNER
Carmel, IN 46032 Invoice #9321 PROJECT NOS.: 082691A ARCIUTE-CT
FROM CONTRACTOR: Hagerman Construction Corporation VIA ARCHITECT: CSO Architects Inc CON rRACTOR
7930 Castleway Drive 280 East 96th Street
Indianapolis, IN 46250 a f Indianapolis, INDIANA 46240 CONTRACI' DATE:
CONTRACT FOR
CONTRACTOR APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractors knowledge, infor-
mation and belief the Work covered by this application for Payment has been completed
Application is trade for payment, as shown below, in connection with the contract. in accordance with the Contract Documents, that all amounts have been paid by the
Continuation Sheet, AIA Document G703 is attached. Contractor for Work for which previous Certificates for Payment were issued and pay-
ments received from the Owner, and that current payment shown herein is now due.
1. ORIGINAL CONTRACT SUM 1. CONTRACT Hagerman Cons ruction Corporation
2. Net change by Change Orders 532.323.00
B Date: April 20� 2009
B y
3. CONTRACT SUM TO DATE (Line 1 $302,473.
Troy Heisler, CFO
State of: Indiana,,
4. TOTAL COMPLETED 8, STORED TO DATE $256,203,0,0 �C,° g \ON gyp/
(Column G on (3703) County of: Allen
`16 9FS e
5. RETAINAGE: Subscribed and swom to before a�1 p` ��e �'s o Q
20th April, 20 9
a 10.000 of Completed Work S25.620.30 me day of
(Columns D E on G703)
c
b. 0 of Stored -Material $Q•QO Notary Pub' �ALh"�•
(Colunuts F on G703) My Commission expires:
12/16/15
Total Retain (L in e
I o nG70 or $25,f)20.30
Total in C ARCHITECT'S CERTIFICATE FOR PAYMENT
Columns I n G703)
6. TOTAL EARNED LESS RETAINAGE S230.582.70 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
(Liuc 6 ftom prior Certificate) ,S207 570.60 quality Of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE ........11..................... $23,012.10 is entitled to payment of the �AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE
AMOUNT CERTIFIED
(Line 3 less line (Attach erplanation if amount certified differs from the amount applled for, Initial
$71,890.30 all ffgtu•es on is Application and on the Continuation Sheet that are changed to
conform r h a unr ce7 ed
ILANGE RDER SUMMARY ADDITIONS DEDUCTIONS ARCIiI 0 i t S c
Total changes approved in
p revious months by Owner $32,323.00, $0.00 Tiy: Date: 30
$0.00 $0,.00
TOTALS 532 323.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
t Contractor named herein. Issuance, payment and acceptance of payment are without
NET CHANGES by Change Order $32,323.00 Dreiudice to any rights of the Owner or Contractor tinder this Contract
AIA DOCUMENT G702• APPLICATION AND CERTIFICATE FOR PAYMENT 1992 EDITION AM C1992 THE AMERICAN INSTITLrrF. OF ARCHITECTS, 1735 NEW YORK 6702 -1992
AVENUE, N.W., WASHINGTON, D.C. 20W,,.5292 WARNING: Unlicensed photocopying violates U.S. copyright laws and will subject the violator to legal prosecution.
"ttds donn+nm Ms Onus mfyoa,ae etac+rmimy wnn da DerMSaim of rnd Artwdem Ir,aJSr° of Ard,e°ds ,v,dn tlooneo 67003 to F+ri,rovv° Symms. 4,c Ropodiftm of dis do=g wtmae ProMct-SPorft W40Mndm Is nM
b ve,n u i wnlon ot tNs do and lanes a.a+a.' Pom 6lod. Ca enct The Am fo,n Inso u'e d An} aCe
CONTINUATION SHEET A IA DOCUMENT G703 PAGE 1 OF I PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: B0006
containing Contractor's signed Certification, is attached, APPLICATION DATE:
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 4/25%2009
Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO.: 082691A
A B C D F. F G H I
WORK COMPLETED NIATEF -LAIS TOTAL BALANCE RE.TAINAGE
ITEM SCHEDULED PRESENTLY COMPLETED o TO IF VARIABLE)
DESCRIPTION OF WORK FROM PREVIOUS /o
NO. VALUE APPLICATION THIS PERIOD STORED t AND STORED FLvISB RATE
(NOT IN TO DATE (G -I (C G)
(D E) D OR E) (D +E +F)
0000010 Rangeline Road Work
0000030 General Conditions $56,800.00 $48,280.00 $5,680.00 $0.00 $53,960.00 95.000 $2,840.00 $0.00
0000040 Existing Conditions Selective Demo $13,150.00 $13,150.00 $0.00 $0.00 $13,150.00 100.000 $0.00 $0.00
0000050 Concrete (Not including Curbs) $36,700.00 $36,700.00 $0.00 $0.00 $36,700,00 100.000 $0,00 $0,00
0000060 Metals $6,580.00 $6,580.00 $0.00 $0.00 $6,580.00 100.000 $0.00 $0.00
0000070 Specialties $8,350.00 $0.00 $0.00 $0.00 $0.00 0 $8,350.00 $0.00
0000080 Electrical $57,950.00 $40,565.00 $5,795,00 $0.00 $46,360.00 80.000 $11,590.00 $0.00
0000090 Earthwork $22,420.00 $22,420.00 $0.00 $0.00 $22,420.00 100.000 $0.00 $0.00
0000100 Exterior improvements $46,980.00 $9,396.00 $14,094.00 $0.00 $23,490.00 50.000 $23,490.00 $0.00
0000110 Utilities $21,220.00 $21,220.00 $0,00 $0.00 $21,220.00 100.000 $0.00 $0.00
0000130 CHANGE ORDER NO. 1
0000140 PC 02 Undercut Work $23,672.00 $23,672.00 $0.00 $0.00 $23,672.00 100.000 $0.00 $0.00
0000160 CHANGE ORDER NO. 03
0000170 PC 03 Alt. Concrete Parkin Lot $8,651.00 $8,651.00 $0.00 $0.00 $8,651.00 100.000 1 $0,00 $0.00
$302,473.00 $230,634.00 $25,569.00 $0.00 $256,203.00 84.70% $46,270.00 $0.00
AIA DOCUMENT G703 APPLICATION AND CERTIFICATE FOR PAYWNT 1992 mrrION AIA( O 1992 THE A- MERIC:AN NsTITUTE OF AROUT£CTS, 1735 NEW YORK 6703 -1992
AVENTF. N.W., WASHINGTON, D.C. 200u6 -5293 WARNING: Unlicensed photocopying violates U.S. copyright laws and will subject the violator to legal prosecution.
This do�t rms t- rsprom-d eNH9vtledy W h ft per -sion of rim Armd- sutlLm of Ardsmot under Ucense 9?= ;o ft,, -M Sye ko. Raprodudsn of dds dowmera Whoa rfojocsspedlc hfomnum is not p- tilted. Corder The Aft+edm InsIme of Arthhecjs
to v" trm ounom -mon of hfs dousryent and #acme va-,
WAIVER OF LIEN
The undersigned isthe duty authodzedofficerof Hagerman Construction Corporation the general contractor,
(Name of Company)
subcontractor,* materialman or other person furnishing the services, labor, material or equipment indicated below in the
construction of improvements upon real estate located in Hamilton County, State of Indiana commonly
known as Parcel 67 Streetscape, rndi i' h real estate Is owned.by Carrel Redevelopt�nt lion "Owner').
Design Center P12
INCONSIDERATION of the sumof Twenty three thousand twelve and 10 /100
DOLLARS �j,nl 2.1 n receipt of which is hereby acknowledged, and in order to procure one or more payments
for services, labor, material or equipment provided in such construction, the Company does hereby waive, release and quit
claim in favor of the Owner of the real estate and the lender or lenders providing funds with which payment of construction
costs is or is to be made, and their assigns, all liens or claim or right to liens upon the land or improvements above*descdbed
which the Company may now have for services, labor, material or equipment furnished in respect of such land or improvements
to and including the date hereof. The undersigned warrants that the Company has not and will not assign any claim for payment
nor any right to perfect a lien against the real estate, and that he has the right to execute this waiver and release of liens on
behalf of himself (herself) and the Company.
The undersigned further warrants and represents that the Company has the right to transfer and does hereby transfer title to
the services, labor, material or equipment to the Owners or lenders named above in consideration of the payment received
hereunder. The undersigned further states that the consideration received hereunder is the sole consideration received by
the Company for said services, labor, material or equipment furnished to date, and that the Company has neither received nor
made any security interest, title retention interest or lien rights in the said services, labor, material or equipment other than that
released and transferred hereby.
The material, labor, services or equipment furnished are more particularly described in the affidavit for payment submitted of
even date herewith. The undersigned further warrants and represents that the Company has compliedwith all prevailing wage
requirements under applicable law or as may be set forth in the contract documents.
WITNESS the execution hereof this 20th day of April 2nn g
arre and Ttle)
Troy Heisler, CFO
Hagerman Construction Corporation
(Name of Company)
State of Indiana County of Allen SS: Before me, the
undersigned, a Notary Public in and for said County and State, personally appeared TT-O uA; S AY'
the cfo of Hagerman Construction Corporation` who acknowledged
(Title) (Name of Company)
the execution of the foregoing Waiver of Lien on behalf of such Company and that the same is the free act and deed of such
Company and the free act and deed of said officer.
WITNESS my hand and notarial seal this 20th day of April 2009
o. ,�o�e�lsS/6, I
My Commission Expires: ber
C c' 9m
CD
Notary Public
12/16/15
NOT A RYSEAL
ot My County of Residence: ��i 6.....• David C. Thomas
(Printed Name of Notary Public)
Allen
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
ri gyrr�,AH CvhSTia�fu, �o +'00�9�;'0>> Purchase Order No.
7 'q 3d 'v� Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
2 2 t_ 1O
i
Total 2 3,` 12 -/O
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
�4c, r rsyJ �hs ✓GC /i IN SUM OF
n
ON ACCOUNT OF APPROPRIATION FOR
9o2 /yy���'6
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
9rf g3 `1 867 230121 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
%J_lj2 20 G
N ?f LAM naao
Sign re
Director of S
Cost distribution ledger classification if Itle
claim paid motor vehicle highway fund