168493 02/04/2009 CITY OF CARMEL, INDIANA VENDOR: 362310 Page 1 of 1
ONE CIVIC SQUARE HAGERMAN CONSTRUCTION CORP
0 CHECK AMOUNT: $162,980.91
�,�a CARMEL, INDIANA 46032 7930 CASTL[WAY DRIVE
INDIANAPOLIS IN 46250 CHECK NUMBER: 168493
CHECK DATE: 2/4/2009
DEPARTMENT ACCOUNT PO NUMBER INVOIC NUMBER AMOUNT DESCRIPTION
902 4460867 A0002 94,787.37 INDIANA DESIGN CENTER
902 4460867 B0002 63,267.39 INDIANA DESIGN CENTER
902 4460867 C0002 4,926.15 INDIANA DESIGN CENTER
APPLICATION AND CERTIFICATE FOR PAYMENT AIADOCUMENTG702 PAGE ONE OF PAGES
TO OWNER: 'f i s,b °C C! m en- C O m m PROJECT: Parcel 67 Streetscape APPLICATION NO: A0002 Distribution to:
720 3rd Avenue SW HCC Job #2691 PERIOD TO: 12/25/2008 OWNER
Carmel, IN 46032 Invoice #9122 PROJECT NOS.: 082691A ARCHITECT
FROM CO NTR TOR: VIA ARCHITECT: CSO Architects Inc El CONTRACTOR
Hagerman Construction Corporation 280 East 96th Street
P .O. Box 10690 Indianapolis, INDIANA 46240 CONTRACT DATE:
Fort Wayne, IN 46853
CONTRACTFOR:
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, infor-
mation and belief the Work covered by this application for Payment has been completed
Application is made 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, ALA 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 $304,600.00 CONTRACTOR-Ha Cons r ion Corporation
2. Net change b Cha Orders $0.00
9 y 9 Date:D 1 9, 2008
Tro H 1 er, CFO
3. CONTRACT SUM TO DATE (L 1 ±2) $304,600.00 Y
4. TOTAL COMPLETED STORED TO DATE State of: Indiana $146.044.50 County o£ Allen
(Column G on G703)
Subscribed and sworn to before O W iSSlON 9
5. RETAINAGE:
@(r e
a. 10.000 of Completed Work $14.604.45 me this 19th day of Dec b 20a �1 t c 9 e
(Columns D +E on G703)
b. 0 of Stored Material Notary l rARV A
$0.00 SC
(Columns F on G703) My Commission expires: 12/161 o co
Total Retainage (Line 5a 5b or $14,604.45 o/ °e
Tota]inColumnslonG703) i.
ARCHITECTS CERTIFICATE FOR }'y,4Y,
6. TOTAL EARNED LESS RETAINAGE $131 440.05 In accordance With the Contract Documents, based on on site observations and the data
(Line 4less 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 from prior Certificate) S36.652 quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE 9 4 ,787.37 1 is entitled to payment of the AMOUNT CERTIFIED_
AMOUNT CERTIFIED
9. BALANCE TO FINISH, INCLUDING RETAINAGE
(Attach explan ion if amormt certified dyers from the amount applied for. Initial,
(Line 3 less Line 6) $173,159.95 all figures t is Application and on the Continuation Sheet that. are changed to
confo to t amo nt cer d.)
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARC TE �f
Total changes approved in Date: Z L o
p revious months b Owner 50.00 $0.00 By
Total appro this Month $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
TOTALS $0.00 $0.00 Contractor named herein. Issuance, payment and acceptance of payment are without
NET CIJANGES by Change Order to any rights of the owne any rights of the Owne o r Contractor under this Contract.
AIA DOCUMENT G702• APPLICATION AND CERTIFICATE FOR PAYMENT 1992 EDITION ALA® 01992 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.
'Thh d—M has boon reprodu d ot°dmnic°It,' rm
Wlh tho peusbn of Tho A-6— lratul° fArchlt° is under Lk— 97001 to pd em Sysletnn, Inr.. Rnpmductlon of this document w thaul p spedlld irformutlon is rtol permitted. Contact The An icon InsUtule cf Amhitea,
to vority th° 1 vo Jan of N, dawmont and lie status.'
wp
CONTINUATION SHEET A IA D G PAGE I OF i PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: A0002
containing Contractor's signed Certification, is attached. APPLICATION DATE:
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 12/25/2008
Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO.: 082691A
A B C D E F G H I
WORKCOMPLETED MATERIALS TOTAL BALANCE RETAMAGE
ITEM DESCRIPTION OF WORK SCHEDULED FROM PREVIOUS PRESENTLY COMPLETED STORED AND STOKED o FINISH TO F VARIABLE)
NO. VALUE APPLICATION THIS PERIOD RATE
(NOT IN TO DATE (C'- C) (C G)
(D E) D OR E) (D +E +F)
0000010 Robert Indiana Street Work
0000030 General Conditions $46,150.00 $6,922.50 $16,152.50 $0.00 $23,075.00 50.000 $23,075.00 $0.00
0000040 Existing Conditions Selective Demolition $8,770.00 $8,770.00 $0.00 $0.00 $8,770.00 100.000 $0.00 $0.00
0000050 Concrete Work Not including Curbs $24,430.00 $0.00 $9,772.00 $0.00 $9,772.00 40.000 $14,658.00 $0.00
0000060 Metals $2,190.00 $1,007.40 $306.60 $0.00 $1,314.00 60.000 $876.00 $0.00
0000070 Specialties $5,570.00 $0.00 $0.00 $0.00 $0.00 0 $5,570.00 $0.00
0000080 Electrical $41,640.00 $832.80 $15,823.20 $0.00 $16,656.00 40.000 $24,984.00 $0.00
0000090 Earthwork $41,500.00 $6,225.00 $18,675.00 $0.00 $24,900.00 60.000 $16,600.00 $0.00
0000100 Exterior Improvements $70,650.00 $10,597.50 $0.00 $0.00 $16,597.50 15.000 $60,052.50 $0.00
0000110 .Utilities $63,700,00 $6,370.00 $44,590.00 $0.00 $50,960.00 80.000 $12,740.00 $0.00
$304,600.00 $40,725.20 $105,319.30 $0.00 $146,044.50 47.95% $158,555.50 $0.00
AIA DOCUMENT G703- APPLICATION AND CERTIFICATr PAYMENT 1992 COITION AIAG 01992 THE AMERICAN INSTITUTE OF ARCEIiTECTS, 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.
'The document hea boon reproduced eloctronkelly with the pemdesfan of Tiw Amed— Inatitule of Architects under !keno 97003 to Primavera Syaton s, Inc. Ropmdudbn of thle down nl without projoc"pecitic Inlomwllcn la rot penNUed. Contact The American lrotlluto d Arrsllecte
to verik Inn moment v"m of this document end Poenee etslus.'
l
WAIVER OF LIEN
The undersigned is the duly authorized office rof 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 Pa rcel 67 Streetscape Indi. &&kh real estate is owned. by Ctr1rel Re3avelmTEnt ommissign "Owner
Design Center P12
IN CONSIDERATIONof the sumof Ninety four thousand seven hundred eighty seven and 37/100
DOLLARS 94, 787.37 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'described
which the Company may now have forservices, labor, material or equipmentfumished 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 forpayment
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 transfertitie to
!fie 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 orequipment furnished to date, and that tho Company has neither received nor
made any security interest, title retention interest or lien rights in the said services, labor, material or equipment otherthan that
released and transferred hereby.
The material, labor, services or equipment furnished are more particularly described li the affidavit for payment submitted of
even date herewith. The undersigned further warrants and represents that the Company has complied with all prevailing wage
requirements under applicable law or as may be set forth In the contract documents.
WITNESS the execution hereof this 19th day of December 90
nd Ttle)
Troy Heis r, CE'0
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 u P
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 19th day of December 200
My Commission Expires:
Z�- G o Notary Public
1
1 6r NOTARYSEAL
Q =w
My County of Residence: �yA,9 <<OVCOiIo Davi Thomas
(Printed Name of Notary Public)
Allen
i
APPLICATION AND CERTIFICATE FOR PAYMENT MADOCUMENTG702 PAGE ONE OF PAGES
TO OWNER: G roc i.; P'_ Redevelopment Comm PROJECT: Parcel 67 Streetscape APPLICATION NO: 130002 Distribution to:
720 3rd Avenue SW HCC Job #2691 PERIOD TO: 12/25/2008 OWNER
Carmel, IN 46032 Invoice #9123 PROJECTNOS.: 082691A ARCHITECT
FROM CONTRACTOR: VIA ARCHITECT: CSO Architects Inc CONTRACTOR
Hagerman Construction Corporation 280 East 96th Street
P.O. BOX 10690 Indianapolis, INDIANA 46240 CONTRACT DATE:
Fort Wayne, IN 46853
CONTR FOR:
CONTRACTOR'S 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 made 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 $270. 150.00
CONTRACTOR:Hagerman C n cti Corporation
2. Net change by Change Orders $23,672.00 B Y Date :D ecember 1 9, 200$
3. CONTRACT SUM TO DATE (Line 1 ±2) $293,822.00 Tr0 el r, CFO
State of: Indiana +(p`�
4. TOTAL COMPLETED STORED TO DATE
$108,684.90 Allen
(Column G on G703) County of:
5. RETAINAGE: Subscribed and swom to before o G
thi 19th December, 200
a. 10.000 of Comp Work $10,868.49 me s a of r
P
(Columns D E on G703)
Notary Publ 0 9 SEq
b. 0 of Stored Material $0- 00 l�
(Columns F on G703) My Commission expires: 12/16/15 y° ��OU1QN fir=
Total Retainage (Line 5a t 5b or $10 ,868.49
ARCHITECT S CERTIFICATE FOR PAYMENT
Total in Cclumns I on G703)
6. TOTAL EARNED LESS RETAINAGE S97, 816.41 In accordance with the Contract Documents, based on on site observations and the data
(Line 4less 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 from prior Certificate) S14 549.02 quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE $63, 267.39 is entitled to payment of the AMOUNT CERTIFIED.
AMOUNT CERTIFIED 1
(Attach 9. BALANCE TO FINISH, INCLUDING RE'TAINAGE
(Attach esplanatio amotmt certifred differs from the amount applied for. Initial
(Line 3 less Line 6) $196,005.59 all figures on rs plication and on the Continuation Sheet that are changed to
�yn` CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Total changes approved in revious months b Owner $0.00 $0.00 Date:
Total al2p roygid this Month $23 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
T OTALS $23 $0.00 Contractor named herein. Issuance, payment and acceptance of payment are without
NET CHANGES by Change Order S23,67 prejudice to any rights of the Owner or Contractor under this Contract.
AJA DOCUMENT G702• APPLICATION AND CERTIFICATE FOR PAYMENT 1992 EDITION AIAO C1992 THE AMERICAN TNSTITUTE OF ARCHITECTS, 1735 NEW YORK 6702 -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.
his d —s,.., has hoon mpmduceet elece —hsiny s Qh the perquion of 1'ho A hm s, Insth.te of Amhuxh undo, Lico m
070M 1. Pmi.vom Swarm. Inc. Reproduclion of this, document without Ptobct- SPednc In'— bn is not p. -Ih.d- Contact rho Arian Instheto d AmliftnIs
to verify the 1 varslon d this document and Boon -a -trues.'
CONTINUATION SHEET AIA DOCUMENT PAGE I OF I PAG
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: B0002
containing Contractor's signed Certification, is attached. APPLICATION DATE:
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 12/25/2008
Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO.: 082691A
A B C D E F G H I
WORICCOMPLECED MATERIALS TOTAL, BALANCE RETAINAGB
ITEM DESCRIPTION OF WORK SCHEDULED FROM PREVIOUS PRESENTLY COMPLETED TO F VARIABLE)
NO. VALUE STORED AND STORED FINISH
APPLICATION THIS PERIOD RATE
(NOT IN TO DATE (G -C) (C G)
(D E) D OR E) (D +E- +F)
0000010 Rangeline Road Work
0000030 General Conditions $56,800.00 $8,520.00 $19,880.00 $0.00 $28,400.00 50.000 $28,400.00 $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 $0.00 $9,175.00 $0.00 $9,175.00 25.000 $27,525.00 $0.00
0000060 Metals $6,580.00 $3,026.80 $0.00 $0.00 $3,026.80 46.000 $3,553.20 $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 $1,159.00 $1,738.50 $0.00 $2,897.50 5.000 $55,052.50 $0.00
0000090 Earthwork $22,420.00 $3,363.00 $3,363.00 $0.00 $0,726.00 30.000 $15,694.00 $0.00
0000100 Exterior Improvements $46,980.00 $7,047.00 $2,349.00 $0.00 $9,396.00 20.000 $37,584.00 $0.00
0000110 Utilities $21,220.00 $2,122.00 $14,854.00 $0.00 $16,976.00 80.000 $4,244.00 $0.00
0000130 CHANGE ORDER NO. 1
0000140 PC 02 Undercut Work $23,672.00 $0.00 $18,937.60 $0.00 $18,937.60 80.000 $4,734.40 $0.00
$293,822.00 $38,387.80 $70,297.10 $0.00 $108,684.90 36.99% $185,137.10 $0.00
AIA DOCUMENT G703- APPLICATION AND CERTIFICATE FOR PAYMENT 1992 EDITION MAO 01992 THE AMERICAN INSTITUTE OF ARCMTEM'S, 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.
This doca -,a has boon mproduced olac srdcelty with tha permission afTha A-6- Imtihde of Mtdlocts -1.1 IJCa rea 97003 b Pd-- Systems. 1- Reproduction of this documaM Whoat p 0ac ,pacifle infomtetlon is not pomitim- Collect The M rit Instltuto of Nchdocts
to -rdV Um -1 voml ar the doaamani and fi-sa smms
WAIVER OF' LIEN
The undersignedisthe duly authorized officerof Hagerman Construction Corporation the general contractor,
(Name of Company)
subcontractor, 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 Indi real estate Is owned,by Carrel Redevelcprant 0anmissicn ("Owner").
Design Center P12
INCONSIDERATION ofthe sum of Sixty three thousand two hundred sixty' seven and 39/100
DOLLARS 63, 267.39 receipt of which Is hereby acknowledged, and in order to procure one or more payments
for services, labor, material or equipment 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'described
which the Company may now have forservices, labor, material orequipmentfumished in respectof such land or improvements
to and includingthe date hereof. Theundersigned warrants thatthe Company has not andwill notassign any ciaimforpayment
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 i
hereunder. The undersigned further states that the consideration received,hereunderis 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.
i
The material, labor, services or equipment furnlshe d are more particularly described in the affidavit for payment submitted of
even date herewith. The undersigned further warrants and represents that the Company has compiled with all prevailing wage
requirements under applicable law or as may be set forth in the contract documents.
WITNESS the execution hereof this 19th day of December X008
i
am and Title)
Troy Heis er CEO
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 r
the cfo of Hagerman Construction Corporation` who acknowledged
(Title) (Name of Company)
the execution of the foregoing Walver 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.
r 19th December 2008
WITNESS my hand and notarial seal this day of
My Commission Expires:
y
12/16/15 e er16,F,P Notary Public
:xo
o 0,
NOI'ARYSEAL
My County of Residence: a�;' David C. Thomas
'yc 9���`N000tS� (Printed Name of Notary Public)
A lle n
APPLIC AND CERTIFICATE FOR PAYMENT AIA DOCUMENT G702 PAGE ONE OF PAGES
TO OWNER C 2 r m ei K ed e v elo m eB L C U r11 ff�, zgft@CT: Parcel 67 Streetscape APPLICATION NO: C0002 Distribution to:
72U .I Averiue sw HCC Job #2691 PERIOD TO: 12/25/2009 Ow:NER
Carmel, IN 46032 Invoice #9124
PROJECT NOS.: 082691.A ARCHITECT
FROM CONTRACTOR. VIA ARCHITECT: CSO Architects Inc CONTRACTOR
Hagerman Construction Corporation 280 East 96th Street
P.O. BOX 10690 Indianapolis, INDIANA 46240 CONTRACT DATE:
Fort Wayne, IN 46853
CONTRACT FOR:
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, infor-
mation and belief the Work covered by this application for Payment has been completed
Application is made 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 $22,050.00 CONTRA R: Hagerman Co WictiOn Corporation
2. Net change by Change Orders $0.00 By: Date: December 1 9, 2008
3. CONTRACT SUM TO DATE (Line 1 =2) $22,050.00 roY i CFO
State of. Indiana
t�0 �FIQ
4. TOTAL COMPLETED STORED TO DATE $5,976.00 r LJ o���j
(Column G on G703) County of: Allen hq�SS10/v °.c$
o s •jp
5. RETAINAGE: Subscribed and swom to before
me this 19th day of December, 2008
a. 10.000 of Completed Work $597.60 Y
(Columns D E on G703) NOTARYSEAL
b. 0 of Stored Material Notary Pu Y
$0.00 q���V^�•J
(Columns F on G703) My Commission expires: 12 16 15
Total Rctainage (Line 5a 5b or $597.60 ARCHITECT'S CERTIFICATE FOR PAYMENT
Total in Columns I on G703)
6, TOTAL EARNED LESS RETAINAGE $5 '37R 40 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
T. LESS PREVIOUS CERTIFICATES FOR PAYMENT Architect's knowledge, information and belief the Work has progressed as indicated, the
(Line 6 from prior Certificate) $452.25 quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE 4 ,926.15 1 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE AMOUNT CERTIFIED $4,926.15 2�
(Line 3 less Line 6) (Attach e.Cpla ton f amount certified differs from the amount applied for. Initial
$16,671.60 all figur� this pplication and on the Continuation Sheet that are changed to
confo to the ount c tilt
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS AR CT
Total changes approved in�
p revious months b Owner $0.00 $0.00 11- Date:
Total approved this Month $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
TOTALS $0.00 $0.00 Contractor named herein. Issuance, payment and acceptance of payment are without
NET CHANGES by Change Order 0.00 prejudice to any rights of the Owner or Contractor under this Contract.
AIA DOCUMENT G702• APPLICATION AND CERTIFICATE FOR PAYMENT 1992 EDITION AlA®• 01992 THE AtviF-R1CAN 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.
�ttl, v«•wn°m n°, o.°n °r,w„�e .+eeo-owy »'nn u.° ✓»�:wn a n. am°nenn m :nrw °rn.d;mets meo. tx.�° atom to Mmev °rn snt.tn., Inc. R°mod�m. d tot. Jxvn,nrt v r°Md :p.ut ��ro�rwn ;a na pmm:n°e. eonmce rn° n�.c°n n :nwin d a.cnn°cn
1 b verily IM am°nl v°nam d <hk documanl and inns. rtatu..
WAIVER 41= LIEN
The undersigned is the dulyauthorized officer of Hagerman Construction Corporatio 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
knownas Parc e 67 Street T ndijincch real estate Is owned .by Carmeal Re3avelcL�tamnissirn "Owner
Design Center P12
INCONSIDEnATIONofthesumof Four thousand nine hundred twenty six and 15/100
DOLLAnS 26.15 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 (fens or claim or right to liens upon the land or Improvements ahove'described
which the Company may now have forservices, labor, material orequlpmentfumished 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 transfertitlo to
fhe 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 soleconsideratlon 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 otherthan 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 complied with all prevailing wage
requirements under applicable law or as may be set forth in the contract documents.
WITNESS the execution hereof this 19th day of December 2nn8
me and Title)
Troy He er, 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 T roy- Hei.51e
the cfo of Hagerman Construction Cornorat-i 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 19th day of December 2008
N r C ���l� iy
My Commission Expires: y
A° Notary Public
ry
1.2/ Cn
My County of Residence: Gb1tlC{.�`e' _David -f Thoma
(Printed Name of Notary Public)
A 1.len
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
Gy4ol Purchase Order No.
h -2 90 Terms
ro'f Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
6T 712 y7,?7 37
!G 3, i,.7,35
'C!
Total
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 tJ
Clerk- Treasurer
z
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF
/61-1 4, 990. 9
ON ACCOUNT OF APPRO FOR
�1 4
Sot
Board Members
PO# or D PT. INVOICE NO. ACCT #/TITLE AMOUNT I hereby certify that the attached invoice(s), or
X02 IV 0002 60,? 6 7 95' 7 37 bill(s) is (are) true and correct and that the
0 I 6 t; 6 3 `i materials or services itemized thereon for
elo 0 Uv I charge is made were ordered and
received except
0/4, o
SignatureV
)r
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund