169036 02/17/2009 CITY OF CARMEL, INDIANA VENDOR: 358569 Page 1 of 1
ONE CIVIC SQUARE KEYSTONE CONSTRUCTION
CARMEL, INDIANA 46032 47 S PENNSYLVANIA -10TH FLOOR CHECK AMOUNT: $30,355.51
INDIANAPOLIS IN 46204
CHECK NUMBER: 169036
CHECK DATE: 2117/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
902 4460847 1 1 26,671.85 HEARTHVIEW OLD TOWN
902 4460848 1 3,683.66 4TH GATEWAY /RANGELINE
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APPLICATION AND CERTIFICATION FOR PAYMENT AL4 DOCUAMATT G 702 PAGE 1 OF 3 PAGES
TO OWNER: PROJECT: APPLICATION NO: I Distribution to:
Carmel Redevleopment Comm. Parcel 47 DOWNER
One Civic Square FX ARCHITECT
Carmel, Indiana 46032 PERIOD TO: 12131108 =CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT:
Keystone Construction Corp. CSO Architects
The Majestic Building 10th Floor PROJECT NOS: 815
47 S. Pennsylvania Street
Indianapolis, IN 46204
CONTRACT FOR: GENERAL CONSTRUCTION CONTRACT DATE:
CONTRACTOR'S' APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge,
Application is made for payment, as shown below, in connection with the Contract. information and beliel'the Work covered by this Application for Payment has been
Continuation Sheet, AIA Document G703, is attached. completed in accordance with the Contract Documents, that all amounts have been paid by
the Contractor for Work for which previous Certificates for Payment were issued and
payments received from the Owner, and that current payment shown herein is now due.
1. ORIGINAL CONTRACT SUM 58,261.00
2. Net change by Change Orders CONTRACTOR: Keystone Construction Corp.
3. CONTRACT SUM TO DATE (Line l f 2) 58,261.00
4. TOTAL COMPLETED STORED TO 26,671.85
DATE (Column G on G703) By: Date: 12/31/08
5. RETAINAGE:
a. 0 of Completed Work State of: 570D 5 A AJ A County of: 111 rA e i O,u
(Column D E on G703) Subscribed and sworn to before me is 3 ay of C a yl QC a0
b. 0 of Stored Material Notary Public:
(Column F on G703) My Commission expires: November 8, 2016
Total Retainage (Lines 5a 5b or
Total in Column I of G703) 0.00 ARCHITECT'S ERTIFI AT F R PAM' ROELL
6. TOTAL EARNED LESS RETAINAGE 26,671.85 In accordance with the Contract Documents, based n on -site observatr�a>t$�F6�diti:
(Line 4 Less Line 5 Total) comprising the application, the Architect certifies t the Owner that to bAFA the
7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge, information and belief the ork has progressewn., I y
PAYMENT (Line 6 from prior Certificate). 0.00 the quality of the Work is in accordance with the ontract Docum�HYs afdttb�QppMjRr
8. CURRENT PAYMENT DUE 26,671.85 is entitled to payment of the AMOUNT CERTIF NOVEMBER 8, 2016
9. BALANCE TO FINISH, INCLUDING RETAINAGE 31,589.15 a
(Line 3 less Line 6) AMOUNT CERTIFIED 'u t7./
CHANGE DRDER SUMMARY ADDITIONS DEDUCTIONS (Attach ex ation if amount certified d fers from the amount applied. Initial all figures on this
Total changes approved Applic ion nd onth ont' uation Sheet that are changed to conform with the amount certified.)
in previous months by Owner ARC ITE T:
Total approved this Month By: Date: �DS
TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
Uontractor named nerem. 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.
40A DOCUMENT G702 APPLICATIOM AND CERT_ICATION FOR PAYMENT 1992 EDITION AIA .01992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE.. N.W., WASHINGTON, DC 2000 6-5292
i~ !Jsers may obtain validation of this document by requesting a completed AIA Document D401 Certification of Document's Authenticity from the Licensee.
CONTINUATION SHEET ALA DOCUMENT G703 PAGE 2OF2 PAGES
AIA Document G702, APPLICATION AND CERTIFICATION FOR PAYMENT, containing APPLICATION NO: 1
Contractor's signed certification is attached. APPLICATION DATE: 12/31/2008
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 12/31/2008
Use Column I on Contracts where variable retainage for line items may apply. PROJECT NO: 815
A B C D E F G H
ITEM DESCRIPTION OF WORK SCHEDULED WORK COMPLETED MATERIALS TOTAL BALANCE RETAINAGE
NO. VALUE FROM PREVIOUS THIS PERIOD PRESENTLY COMPLETED (G C) TO FINISH (IF VARIABLE
APPLICATION STORED AND STORED (C G) RATE)
(D E) (NOT IN TO DATE
D OR E) (D+E +F)
1 General Conditions Estimate $24,761.00 $18,871.85 $18,871.85 76.22% 5,889.15 $0.00
2 5% Construction Management Fee Estimate $33,500.00 $7,800.00 $7,800.00 23.28% 25,700.00 $0.00
PAGE TOTAL $58,261.00 $0.00 $26,671.85 $0.00 $26,671.85 45.78% $31,589.15 $0.00
Users may obtain validation of this document by requesting of the license a completed AIA Document D401 Certification of Document's Authenticity
Prescribp.d 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.
I
P ayee
llt°ys�on C o° srrvra� Co'�, Purchase Order No.
y Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
4 1 7 7� 2-
Total 211 i6
1 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
�OnSI /rim /76'�
rl P /L' j o y /G/7 r IN SUM OF
2
ON ACCOU r ^r °R AT FOR
0/0
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
/60e 24(7( 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
2 2 0 o y
6cHd
ig ature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
APPLICATION AND CERTIFICATION FOR PAYMENT AL4D0CU1VMNTG702 PAGE I OF 3 PAGES
TO OWNER: PROJECT: APPLICATION NO: I Distribution to:
Carmel Redevleopment Comm. Parcel 48 Gateway 4 FX OWNER
One Civic Square ARCHITECT
Carmel, Indiana 46032 PERIOD TO: 12131108 =CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT:
Keystone Construction Corp. CSO Architects
The Majestic Building 10th Floor PROJECT NOS: 815
47 S. Pennsylvania Street
Indianapolis, IN 46204
CONTRACT FOR: GENERAL CONSTRUCTION CO D AT E:
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge,
Application is made for payment, as shown below, in connection with the Contract. information and belief the Work covered by this Application for Payment has been
Continuation Sheet, AIA Document G703, is attached. completed in accordance with the Contract Documents, that all amounts have been paid by
the Contractor for Work for which previous Certificates for Payment were issued and
payments received from the Owner, and that current payment shown herein is now due.
J. ORIGINAL CONTRACT SUM 36,079.00
2. Net change by Change Orders CONTRACTOR: Keystone Construction Corp.
3. CONTRACT SUM TO DATE (Line 1 f 2) 36,079.00
4. TOTAL COMPLETED STORED TO 3,683.66
DATE (Column G on G703) By: Date: 12/31/08
5. RETAINAGE:
a. 10 of Completed Work State of: =jUp� A f} County of:
(Column D_ E on G703) Subscribed and s orn t bef t day, of
b. 10 of Stored Material Notary Public:
(Column F on G703) My Commission expires: M. ROEtl
Total Retainage (Lines 5a 5b or l I NOTARY PUSUC
Total in Column I of G703) 0.00 ARCHITECT RTI FI P
6. TOTAL EARNED LESS RETAINAGE 3,683.66 In accordance with the Contract Documents, b d on on -site obs to
(Line 4 Less Line 5 Total) comprising the application, the Architect certifi to the Owner ffiQVV d�82 Mfi8ES:
7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge, information and belief a Wor
PAYMENT (Line 6 from prior Certificate) 0.00 the quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE 3, 683.66 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE 32,395.34
(Line 3 less Line 6) AMOUNT CERTIFIED
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach ex on if amount certified differs from the amount applied. Initial all figures on this
Total changes approved App
licati a d e Con cation Sheet that are changed to conform with the amount certified.)
in previous months by Owner ARC
Total approved this Month By: Date:
TOTALS $0.00 1 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
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 CERTIFICATION FOR PAYMENT 1992 EDITION AIA ®1992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE., N.W.. WASHINGTON, DC 2000&5292
I Users may obtain validation of ulis document by requesting a completed AIA Document D401 Certification of Document's Authenticity from the Licensee.
_CONTINUATION SHEET AIA DOCUMENT G703 PAGE 2 6F 2 PAGES
AIA Document G702, APPLICATION AND CERTIFICATION FOR PAYMENT, containing APPLICATION NO: 1
Contractor's signed certification is attached. APPLICATION DATE: 12/31/2008'
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 12/31/2008
Use Column I on Contracts where variable retainage for line items may apply. PROJECT NO: 815
A B C D E F G H I
ITEM DESCRIPTION OF WORK SCHEDULED WORK COMPLETED MATERIALS TOTAL BALANCE RETAINAGE
NO. VALUE FROM PREVIOUS THIS PERIOD PRESENTLY COMPLETED (G C) TO FINISH (IF VARIABLE
APPLICATION STORED AND STORED (C G) RATE)
(D E) (NOT IN TO DATE
D OR E) (D+E +F)
1 General Conditions Estimate $22,658.00 $2,890.70 $2,890.70 12.76% 19,767.30 $0.00
2 5% Construction Management Fee Estimate $13,421.00 $792.96 $792.96 5.91% 12,628.04 $0.00
PAGE TOTAL $36,079.00 $0.00 $3,683.66 $0.00 $3,683.66 10.21% $32,395.34 $0.00
Users may obtain validation of this document by requesting of the license a completed AIA Document D401 Certification of Document's Authenticity
•c- Prescribid 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
�e:5�V5 ov�,e �o��3�rvc7� Cuero Purchase Order No.
q7 SUt/fy Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Iz�d /�o8 Co »�rr��f i✓�� /1914 P�� �8 �Qf��' �f 3 6��. G6
Total 3 0
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.
y
ALLOWED 20
7 ��r3'G �v /ate f IN SUM OF
1 1 7 S- 1�-,7e!
ON 9e 1ATION FOR
ill
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
which charge is made were ordered and
received except
20 y
Signature
Cost distribution ledger classification if We
claim paid motor vehicle highway fund