HomeMy WebLinkAbout178526 10/26/2009 CITY OF CARMEL, INDIANA VENDOR: 362310 Page 1 of 1
ONE CIVIC SQUARE HAGERMAN CONSTRUCTION CORP
4 i CHECK AMOUNT: $4,375.00
CARMEL, INDIANA 46032 7930 CASTLEWAY DRIVE
o INDIANAPOLIS IN 46250 CHECK NUMBER: 178526
CHECK DATE: 10/26/2009
DEPARTMEN ACCOUNT PO NUMBER INVOICE NUMBER AMOUN DESCRIPTION
902 4460807 16 4,375.00 ENERGY CENTER
r AI A r�
TM
D ®current G7�21CMa —1992
Application and Certificate for Payment Construction Manager- Adviser Edition S,,b
TO OWNER: PROJECT: CCC- Energy Center Parcel 7C APPLICATION NO 1 6
Distribution to:
Carmel Redevelgpment 'Commission HCC Job #2555 PERIOD TO 04/30/09 OWNER
City of Cartnel Invoice #9306
Carmel, IN;46032 CONSTRUCTION MANAGER
FROM CONTRACTOR: VIA CONSTRUCTION MANAGER: CONTRACT DATE: ARCHITECT
Hagerman Construction Corporation Shiel Sexton PROJECT NOS: I I CONTRACTOR
P.O. Box 10690 2805
Fort Wayne, IN 46853 VIA ARCHITECT: FIELD
CONTRACT FOR: CSO Architects
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and
Application is made for payment, as shown below, in connection with the Contract- belief the Work covered by this Application for Payment has been completed in accordance with the
Continuation Sheet AIA Document G703, is attached. Contract Documents, that all amounts have been paid by the Contractor for Work for which previous
1, l38 ,000 .00 Certificates for Payment were issued and payments received from the Owner, and that current
1. ORIGINAL CONTRACT SUM payment shown herein is now due.
2. Net change by Change Orders 303, 929. CONTRACTOR Hagerman Constru on Corporation
3. CONTRACT SUM TO DATE (Line 1 2) 1 ,441 929. By: Date: +jrIt 15 2009
4. TOTAL COMPLETED ill STORED TO DATE (Column G on G703) 1 ,439,589. 00 Stat of: oy e> s r `Qp. N
5. RETAINAGE:
County of:
Allenna Gp
%a M��S /pN q
a. of;Completed Work Subscribed and sworn to before ��tp6er�A;
(Column D E on G703) 72 096.45 me this 1
c O o cn
b (Column
of Stored F on G70Material My Commission expires: 1 5 NOTgpy
Total Retainage (Lines 5a 5b or Total in Column I of G703).. 72,096 CERTIFICATE FOR PAYMENT
In accordance with the Contract Documents, based on on -site observatio data comprising
6. TOTAL EARNED LESS RETAINAGE 1,367 this application, the Construction Manager and Architect certify to the Owner that to the best of their
(Line 4 Less Line 5 Total) knowledge, information and belief the Work has progressed as indicated, the quality of the Work is in
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT 11 accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT
(Line 6 from prior Certificate) CERTIFIED.
6. CURRENT PAYMENT DUE 4,375, AMOUNT CERTIFIED
9. BALANCE TO FINISH, INCLUDING RETAINAGE (Attach explanation if amount certified differs from the amount: applied. Initial all figures on this
Application and on the Continuation Sheet that are changed to conform with the amount certified.)
(Line 3 less Line 6) 74,436.45 Q r/ CONSTRUCTION MANAGER:
By: Date:
ADDITIONS DEDUCTIONS
CHANGE ORDER SUIvIiviARY ARCHITECT:
Total changes approved in previous months by Owner %04,804.00 875.00 By: Date:
Total approve&rhis'Month —0— This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor
TOTALS SO4,804.00 named herein. Issuance payment and acceptance of payment are without prejudice to any rights of
NET CHANGES by Change Order 903,929 00 the Owner or Contractor under this Contract.
CAJ71Gi 1: Ycu s sign an original NA Contract Recurrent, cn which this text appears in RED. An original assures that caarges will net be cbscurad.
AIA Document G702/CMaTM —1992. Copyright 1992 by The American Institute of Architects. All rights reserved, WARMU IG: This AIA' Dccument is protected by U.S. Copyright Law and International Treaties.
'inautiicrized reprcduciicn or distribution of this AIA' Document, or any portion of it, may result in severs civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law.
Purchasers are permitted to reproduce ten (10) copies of this document when completed. To report copyright violations of AIA Contract Documents, a -mail The American Institute of Architects' legal counsel, copyright(?a aia.org.
CONTINUATION SHEET AI DO G703 PAGE I OF 5 PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 00016
containing Contractor's signed Certification, is attached. APPLICATION DATE:
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 4/3012009
Use Column I on Contracts where variable retainage for line items may apply. ARCHITECTS PROJECT NO.: 072555A
A B C D E F G H 1
WORK COM PLETED MATERIALS TOTAL BALANCE RETAINAGE
ITEM
PRESENTLY COMPLETED VARIABLE)
SCHEDULED FROM PREVIOUS TO
DESCRIPTION OF WORK SC
NO. VALUE STORED AND STORED
APPLICATION THIS PERIOD (NOT IN TO DATE (G =C) (C G) RATE
(C G)
(D E) D ORE) (D+E +F)
0000010 GENERAL CONDITIONS
0000020 Bond $10,000.00 $10,000.00 $0.00 $0.00 $10,000.00 100.000 $0.00 $0.00
0000030 General Conditions $11,500.00 $11,500.00 $0.00 $0.00 $11,500.00 100.000 $0.00 $0.00
0000040 Mobilization $2,500.00 $2,125.00 $375.00 $0.00 $2,500.00 100.000 $0.00 $0.00
0000050 Supervison/ Engineering $40,000.00 $39,600.00 $400.00 $0.00 $40,000.00 100.000 $0.00 $0.00
0000060 Cleanup Allowance $18,000.00 $15,660.00 $0.00 $0.00 $15,660.00 87.000 $2,340.00 $0.00
0000070 Dumpsters $10,000100 $10,000.00 $0,00 $0.00 $10,000.00 100.000 $0.00 $0.00
0000080 Toilets $3,500.00 $3,500.00 $0.00 $0.00 $3,500.00 100.000 $0.00 $0.00
0000090 Owner Allowance $3,000.00 $3,000.00 $0.00 $0.00 $3,000.00 100.000 $0.00 $0.00
0000100 Subtotal General Conditions $98,500.00 $95,385.00 $775.00 $0.00 $96,160.00 97.624 $2,340.00 $0.00
0000120 EARTHWORK
0000130 Excavation/ Backfill $256,000.00 $256,000.00 $0.00 $0.00 $256,000.00 100.000 $0.00 $0.00
0000140 Subtotal Earthwork $256,000.00 $256,000.00 $0.00 $0.00 $256,000.00 100.000 $0.00 $0.00
0000160 CONCRETE
0000170 Pile Caps Labor $15,000.00 $15,000.00 $0.00 $0.00 $15,000.00 100.000 $0.00 $0.00
0000180 Pile Caps Material $16,000.00 $16,000.00 $0.00 $0.00 $16,000.00 100.000 $0.00 $0.00
0000190 Foundations Labor $26,000.00 $26,000.00 $0.00 $0,00 $26,000.00 100.000 $0,00 $0.00
0000200 Foundations Material $14,000.00 $14,000.00 $0.00 $0.00 $14,000.00 100.000 $0.00 $0.00
0000210 Pit Labor $10,000.00 $10,000.00 $0.00 $0.00 $10,000.00 100.000 $0.00 $0.00
0000220 Pit Material $11,000.00 $11,000.00 $0.00 $0.00 $11,000.00 100.000 $0.00 $0.00
0000230 Slab on Grade Labor $13,000,00 $13,000.00 $0,00 $0.00 $13,000.00 100.000 $0.00 $0.00
0000240 Slab on Grade Material $15,000.00 $15,000.00 $0.00 $0.00 $15,000.00 100.000 $0.00 $0.00
0000250 Elevated Slabs Labor $4,000.00 $4,000.00 $0.00 $0.00 $4,000.00 100.000 $0.00 $0.00
0000260 Elevated Slabs Material $9,000.00 $9,000.00 $0.00 $0.00 $9,000.00 100.000 $0.00 $0.00
0000270 Tunnel Base Labor $29,000.00 $29,000.00 $0.00 $0.00 $29,000.00 100.000 $0.00 $0.00
0000280 Tunnel Base Material $41,000.00 $41,000.00 $0.00 $0.00 $41,000.00 100.000 $0.00 $0.00
0000290 Tunnel Walls Labor $92,000.00 $92,000.00 $0.00 $0.00 $92,000.00 100.000 $0.00 $0.00
0000300 Tunnel Walls Material $57,000.00 $57,000.00 $0.00 $0.00 $57,000.00 100.000 $0.00 $0.00
0000310 Tunnel Top Labor $41,000.00 $41,000.00 $0.00 $0.00 $41,000.00 100.000 $0.00 $0.00
0000320 Tunnel Top Material $38,000.00 $38,000.00 $0.00 $0.00 $38,000.00 100.000 $0.00 $0.00
0000330 Rebar Labor $52,000.00 $52,000.00 $0.00 $0.00 $52,000.00 100.000 $0.00 $0.00
0000340 Rebar Material $75,000. $75,000.00 $0.00 0.001 $7 5,000.00 100.000 $0,00 $0.00
ALA DOCUMENT G703• APPLICATION AND CERTIFICATE FOR PAYMENT 1992 EDITION AIA 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.
Tes doaaoent Mpm CW elegJPreoally wllll It1e pemieaipr of The Am.J= 1- dttde't Atd*W-13 under Liaonc¢ 97003 to Pnma Sys Inc RepreducWn of ft, dewment wf h-A Prpl- 0 -Pedfk -form U- q M om
ptlead, Cont Ameriten
ea The Etetltede d AndtReCe
to verRV the w eM ve"_ a Mb docunem and acense atatua.'
CONTINUATION SHEET AIA D O C UMENT G70 PAGE 2 OF 5 PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 00016
containing Contractor's signed Certification, is attached. APPLICATION DATE:
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 4/30/2009
Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO.: 072555A
A B C D E F G H 1
WORK COMPLETED MATERIALS TOTAL BALANCE
ITEM SCHEDULED PRESENTLY COMPLETED d TO RETAINAGE
DESCRIPTION OF WORK FROM PREVIOUS VARIABLE)
NO. HI
VALUE APPLICATION TS PERIOD STORED AND STORED FINISH
(NOT IN TO DATE (G -C) (C G)
(D E) D OR E) (D+E +F)
0000350 Subtotal Concrete $558,000.00 $558,000.00 $0.00 $0.00 $558,000.00 100.000 $0.00 $0.00
0000370 GENERAL TRADES
0000380 Waterproofing $69,000.00 $69,000.00 $0.00 $0.00 $69,000.00 100.000 $0.00 $0.00
0000390 Insulation $7,000.00 $7,000.00 $0.00 $0.00 $7,000.00 100.000 $0.00 $0.00
0000400 Firestopping $3,000.00 $3,000.00 $0.00 $0.00 $3,000.00 100.000 $0.00 $0.00
0000410 Caulking $3,000.00 $3,000.00 $0.00 $0.00 $3,000.00 100.000 $0.00 $0.00
0000420 Doors Labor $4,000.00 $4,000.00 $0.00 $0.00 $4,000.00 100.000 $0.00 $0.00
0000430 Doors! Hardware Material $21,000.00 $21,000.00 $0.00 $0.00 $21,000.00 100.000 $0.00 $0.00
0000440 Glazing $500.00 $500.00 $0.00 $0.00 $500.00 100.000 $0.00 $0.00
0000450 Acoustic Ceilings $1,500.00 $1,500.00 $0.00 $0.00 $1,500.00 100.000 $0.00 $0.00
0000460 Acoustic Panels Labor $14,000.00 $14,000.00 $0.00 $0.00 $14,000.00 100.000 $0.00 $0.00
0000470 Acoustic Panels Material $48,000.00 $48,000.00 $0.00 $0.00 $48,000.00 100.000 $0.00 $0.00
0000480 Resinous Flooring $12,000.00 $8,400.00 $3,600.00 $0.00 $12,000.00 100.000 $0.00 $0.00
0000490 Painting $40,000.00 $40,000.00 $0.00 $0.00 $40,000.00 100.000 $0.00 $0.00
0000500 Signs $2,000.00 $2,000.00 $0.00 $0.00 $2,000.00 100.000 $0.00 $0.00
0000510 Toilet Accessories $500.00 $500.00 $0.00 $0.00 $500.00 100.000 $0.00 $0.00
0000520 Subtotal General Trades $225,500.00 $221,900.00 $3,600.00 $0.00 $225,500.00 100.000 $0.00 $0.00
0000540 CHANGE ORDER #1
0000550 PC #2 Temporary Fencing $19,195.00 $19,195.00 $0.00 $0.00 $19,195.00 100.000 $0.00 $0.00
0000590 CHANGE ORDER #2
0000600 PC#01 R3 Trash Sleeves Under Tunnel $6,973.00 $6,973.00 $0.00 $0.00 $6,973.00 100.000 $0.00 $0.00
0000640 CHANGE ORDER #3
0000650 PC #21 R1 Mech Tunnel Mud Slab $22,306.00 $22,306.00 $0.00 $0.00 $22,306.00 100.000 $0.00 $0.00
0000670 CHANGE ORDER #4
0000680 PC #14 Dewatering $19,722.00 $19,722.00 $0.00 $0.00 $19,722.00 100.000 $0.00 $0.00
0000711 CHANGE ORDER #5
0000712 PC #20R1 Dewatering $17,602.00 $17,602.00 $0.00 $0.00 $17,602.00 100.000 $0.00 $0.00
AIA DOCUMENT G703• APPLICATION AND CERTIFICATE FOR PAYMENT 1992 EDITION AIAV C1992 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.
'rh. douanero ties hems repr d-d eteNOnldly with dte pmmltabn of The AmaAen VWMUb Of Aidetaets rde Lieabe 97003 b P-- Sr -M11, hx Rep on poducd d this doamwt -*hma prOs'aP-Cb Idmmmbn b rot p+nrdmd. Comet The A- 4.*C o d Artddiedt�
tO t r
he aem vmebn of thh doa d and 9cmtse atmua.'
CONTINUATION SHEET A D O C UMENT G 703 PAGE 3 OF 5 PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 00016
containing Contractor's signed Certification, is attached. APPLICATION DATE.
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 4/3012009
Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO.: 072555A
A B C D E F G H I
WORK COMPLETED MATERIALS TOTAL BALANCE
PRESENTLY COMPLETED A AGE
ITEM DESCRIPTION OF WORK SCHEDULED FROM PREVIOUS STORED AND STORED V
NO. VALUE APPLICATION THIS PERIOD (NOT IN TO DATE (G -C) FINISH
(C G) F VARIABLE)
ARI ABLE)
RATE
(D E) D OR E) (1 +E +F)
0000720 CHANGE ORDER #6
0000730 PC #22 Bad Soils at Mech Tunnel $12,221.00 $12,221.00 $0.00 $0.00 $12,221.00 100.000 $0.00 $0.00
0000740 PC #23 Bad Soils at Mech Tunnel $7,588.00 $7,588.00 $0.00 $0.00 $7,588.00 100.000 $0.00 $0.00
0000750 Subtotal CO #6 $19,809.00 $19,809.00 $0.00 $0.00 $19,809.00 100.000 $0.00 $0.00
0000770 CHANGE ORDER #7
0000780 PC #24 Delete 2' Bump Out ($338.00) ($338.00) $0.00 $0.00 ($338.00) 100.000 $0.00 $0.00
0000800 CHANGE ORDER #8
0000810 PC #09R1 7' Additional Tunnel (50 $19,160.00 $19,160.00 $0.00 $0.00 $19,160.00 100.000 $0.00 $0.00
0000830 CHANGE ORDER #9
0000840 PC #05R3 -A Shared East Wall at Bldg. $21,276.00 $21,276.00 $0.00 $0.00 $21,276.00 100.000 $0.00 $0.00
0000860 CHANGE ORDER #10
0000870 PC #05R3 -B Shared East Wall at Courtyard $33,581.00 $33,581.00 $0.00 $0.00 $33,581.00 100.000 $0.00 $0.00
0000890 CHANGE ORDER #11
0000900 PC #05R3 -C Shared East Wall North of Cou $33,620.00 $33,620.00 $0.00 $0.00 $33,620.00 100.000 $0.00 $0.00
0000920 CHANGE ORDER #12
0000930 PC #12R1 Additional Fencing Work $1,232.00 $1,232.00 $0.00 $0.00 $1,232.00 100.000 $0.00 $0.00
0000950 CHANGE ORDER #13
0000960 PC #16R1 Subdrainage along Tunnel $16,920.00 $16,920.00 $0.00 $0.00 $16,920.00 100.000 $0.00 $0.00
0000980 CHANGE ORDER #14
0000990 PC #25 Mechanical Pit Access Lid $2,289.00 $2,289.00 $0.00 $0.00 $2,289.00 100.000 $0.00 $0.00
0001010 CHANGE ORDER 915
0001020 PC #11 R2 RFQ EC 10 ESI Enlarge Mechanic $7,744.00 $7,744.00 $0.00 $0.00 $7,744,00 100.000 $0.00 $0.00
0001040 CHANGE ORDER #16
0001050 PC #15 Delete 2' x 8' Louver ($459.00) ($459.00) $0.00 $0.00 ($459.00) 100.000 $0.00 $0.00
ALA DOCUMENT G703• APPLICATION AND CERTIFICATE FOR PAYMENT 1992 EDITION AIA® C1992 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.
'This doctananl has been mprodu d eiammcally with the petmbson of TTa AnWWn Insauto of Archoeog moor Ucanw 97003 to PMi ete SyeteTS. Int, Reproduction of rds dooanent wanout Poles' affonnatbn 4s not pannlaed. Contact The American IAStraM of ArWleds
to varoy tha -wft lemon of of do -nant and ncense status.-
CONTINUATION SHEET AIA D G703 PAGE 4OF 5 PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 00016
containing Contractor's signed Certification, is attached. APPLICATION DATE:
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 4/30/2009
Use Column I on Contracts where variable retainage for line items may apply. ARCHITECTS PROJECT NO.: 072555A
A B C D E F G H I
WORK COMPLETED MATERIALS TOTAL BALANCE RETAINAGE
ITEM DESCRIPTION OF WORK SCHEDULED FROM PREVIOUS PRESENTLY COMPLETED TO VARIABLE)
NO. VALUE APPLICATION THIS PERIOD STORED AND STORED FINISH RATE
(NOT IN TO DATE (G -C) (C G)
(D E) D OR E) (D+E +F)
0001070 CHANGE ORDER #17
0001080 PC #13R1 Added Dowel Bar Replacement $10,476.00 $10,476.00 $0.00 $0.00 $10,476.00 100.000 $0.00 $0.00
0001100 CHANGE ORDER #18
0001105 PC #03 Truck Wash Pad $4,992.00 $4,992.00 $0.00 $0.00 $4,992.00 100.000 $0.00 $0.00
0001110 PC #2 Temporary Fencing ($216.00) ($216.00) $0.00 $0.00 ($216.00) 100.000 $0.00 $0.00
0001120 PC #3 Truck Wash Pad ($325.00) ($325.00) $0.00 $0.00 ($325.00) 100.000 $0.00 $0.00
0001130 Subtotal CO #18 $4,451.00 $4,451.00 $0.00 $0.00 $4,451.00 100.000 $0.00 $0.00
0001150 CHANGE ORDER #19
0001160 PC #3081 Dewatering $2,058.00 $2,058.00 $0.00 $0.00 $2,058.00 100.000 $0.00 $0.00
0001180 CHANGE ORDER #20
0001190 PC #18 Door Hardware Modifications $3,006.00 $3,006.00 $0.00 $0.00 $3,006.00 100.000 $0.00 $0.00
0001200 PC #31 Concrete Door Base at Courtyard $780.00 $780.00 $0.00 $0.00 $780.00 100.000 $0.00 $0.00
0001210 Subtotal CO #20 $3,786.00 $3,786.00 $0.00 $0.00 $3,786.00 100.000 $0.00 $0.00
0001230 CHANGE ORDER #21
0001240 PC #43R2 Drain Tile Modifications $24,000.00 $24,000.00 $0.00 $0.00 $24,000.00 100.000 $0.00 $0.00
0001260 CHANGE ORDER #22
0001270 PC #40 Eliminate Exterior Signage ($875.00) ($875.00) $0.00 $0.00 ($875.00) 100.000 $0.00 $0.00
0001290 CHANGE ORDER #23
0001300 PC #35112 2 Fire Extinguisher 1 Mirror $745.00 $745.00 $0.00 $0.00 $745.00 100.000 $0.00 $0.00
0001320 CHANGE ORDER #24
0001330 PC #17 Dewatering $732.00 $732.00 $0.00 $0.00 $732.00 100.000 $0.00 $0.00
0001340 PC #32R1 Dewatering $8,012.00 $8,012.00 $0.00 $0.00 $8,012.00 100.000 $0.00 $0.00
0001350 PC #33 Dig Well for Dewatering $1,627.00 $1,627.00 $0.00 $0.00 $1,627.00 100.000 $0.00 $0.00
0001360 PC #38 Dewatering $3,635.00 $3,635.00 $0.00 $0.00 $3,635.00 100.000 $0.00 $0.00
0001370 PC #42 Dewatering $805.00 $805.00 $0.00 $0.00 $805.00 100.000 $0.00 $0.00
0001380 PC #45 Dewatering $2,327.00 $2,327.00 $0.00 $0.00 $2,327.00 100.000 $0.00 $0.00
ALA DOCUMENT G703• APPLICATION AND CERTIFICATE FOR PAYMENT 1992 EDITION AIA® C1992 THE AMERICAN INSTrIZJiE OF ARCHITECTS, 1735 NEW YORK G703 -1992
AVENUE, N.W., WASHINGTON, D.C. 200065292 WARNING: Unlicensed photocopying violates U.S. copyright laws and will subject the violator to legal prosecution.
'This dowmenl has been MprodMed eleamnimlly adh the penrussbn of The A-iMn In3t"e of AM"MM a under LIC- 97003 to Pn naves Syafana, Ind. RwvduCbn d NIS om..m m,,A p,qj,- ,P -C1r- information Is not p-Mod. Contact The Amenran In MLft of AMhit.=
to vedfv the anera vetyon W Nis ddcynent and karma atetue
CONTINUATION SHEET AIA DOCUMENT G703 PAGE 5 OF 5 PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 00016
containing Contractor's signed Certification, is attached. APPLICATION DATE:
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 4/30/2009
Use Column I on Contracts where variable retainage for line items may apply. ARCHITECTS PROJECT NO.: 072555A
A B C D E F G H I
WORK COMPLETED MATERIALS E(D+E+F) BALANCE RETAWAGE
PRESENTLY VARIABLE)
ITEM
DESCRIPTION OF WORK SCHEDULED FROM PREVIOUS TO
NO. VALUE APPLICATION THIS PERIOD STORED FINISH RATE
(NOT IN (G C) (C G)
(D E) D OR E)
0001390 Subtotal CO #24 $17,138.00 $17,138.00 $0.00 $0.00 $17,138.00 100.000 $0.00 $0.00
0001410 CHANGE ORDER #25
0001420 PC #45 Paint Changes on Roof $1,518.00 $1,518.00 $0.00 $0.00 $1,518.00 100.000 $0.00 $0.00
$1,441,929.00 $1,435,214.00 $4,375.00 $0.00 $1,439,589.00 99.84% $2,340.00 $0.00
AIA DOCUMENT G703• APPLICATION AND CERTIFICATE FOR PAYMENT 1992 EDITION AIA® 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.
'Tiffs 9. M has been mpmdreed eteceertica�N wIN Na pmninion of The Amerkan ImtlGne of Amt" under llcerne 97003 W f d-- Systems, in. ReproduaW of a. dmmem wiNM pmJeawearn NW-26M is not pemetWd. Coma The Amerk= NsmLu of Adreeas
vrity Ne m m version of Nis document arq Otaua teou.'
W eMV s
WAIVER OF LIEN
The undersigned is the duly authorized officer of Pagerm non canst l� tiOn 0-- the generalcontracto;
(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 Carmel Energy Center which real estate is owned by Carmel Redevelopment "Owner").
Commission
1NGONSIDERATIONofthesumof Four thousand three hundred seventy five and 00 /100
DOLLARS 4,375.00 1 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 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 claimforpayment
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 transfertitle 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 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 15th day of April 2009
N mPd Title)
Troy Heisl�r,
Hgennan Onnetnict,•inn rnrporation
(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 Troy Heisler
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 15th day pf April 2009
X 16,20/ 5 S 6
My Commission Expires: Q om ;Q�
O Notary Public
My County of Residence: SHY PUF
David C. Thomas
(Printed Name of Notary Public)
Allen
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
�G <�57�' rl_� 'oh ('o V/✓ory�i !ice Purchase Order No.
/065'0 Terms
f l'� y' ,1 5� Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Woo /o9
a
Total y,3 �soa
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
ON ACCOUNT OF APPROPRIATION FOR
(1 E�
�0
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
y375 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
Q� ,2 oU
Sign ure
Director of Operations
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund