177999 10/13/2009 CITY OF CARMEL, INDIANA VENDOR: 358569 Page 9 of 1
ONE CIVIC SQUARE KEYSTONE CONSTRUCTION
CARMEL, INDIANA 46032 47 S PENNSYLVANIA -10TH FLOOR CHECK AMOUNT: $958.30
'a INDIANAPOLIS IN 4620A
CHECK NUMBER: 177999
CHECK DATE: 1 011 312 0 09
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
902 4460848 5 958.30 4TH GATEWAY /RANGELINE
APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE 1 OF 3 PAGES
TO OWNER: PROJECT: APPLICATION NO: 5 Distribution to:
Carmel Redevleopment Comm. Parcel 48 Gateway 4 OWNER
One Civic Square ARCHITECT
Carmel, Indiana 46032 PERIOD TO: 8125109 =CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT:
Keystone Construction Corp. CSOArchilects
The Majestic Building I Oth Floor PROJECT NOS: 815
47 S. Pennsylvania Street
Indianapolis, IN 46204
CONTRACT FOR: GENERAL CONSTRUCTION CONTRACT D ATE:
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 6703, 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
2. Net change by Change Orders CONTRACTOR: Keystone Construction Corp.
3. CONTRACT SUM TO DATE (Line 1 f 2)
4. TOTAL COMPLETED STORED TO 19,460.47
DATE (Column G on G703) By: Date: 8/25/09
5. RETAINAGE:
a. 10 %of Completed Work State of: Indiana County of. Marion
(Column D E on G703) Subscribed and wo to before this 25 day of August 2009.
b. 10 of Stored Material Notary Public:
(Column F on G703) My Commission expires: 11/08/2016
Total Retainage (Lines 5a 5b or
total in Column I of G703) ARCHITECT'S CERTIFICATE FOR PAYMERT
6. TOTAL EARNED LESS RETAINAGE 19,460.47 In accordance with the Contract Documents, based on on -site observations and the data
(Line 4 Less Line 5 Total) comprising the application, the Architect certifies to the Owner that to the best of the
7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge, information and belief the Work has progressed as indicated,
PAYMENT (Line 6 from prior Certificate) 18,502.17 the quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE 958.30 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH. INCLUDING RETAINAGE p
(Line 3 less Line 6) AMOUNT CERTIFIED 56,'0
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach exp natio ifamaunt certified differs from the amount applied. Initial all figures on this
Total changes approved Applicat n and the Con u ion Sh that are changed to conform with the amount certified.)
in previous months by Owner ARCH CT: 7
Total approved this Month By: Date:
TOTALS $0.00 $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 01992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE.. N.W., WASHINGTON, DC 20006 -5292
Users m;;: n of this document by requesting a completed AIA Document D401 Certification of Document's Authenticity from the Licensee.
COW I N U AT I O N SHEET ALA DOCUMENT G703 PAGE 2 OF 2 PAGES
AIA Document G702, APPLICATION AND CERTIFICATION FOR PAYMENT, containing APPLICATION NO: 5
Contractor's signed certification is attached. APPLICATION DATE: 8/25/2009
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 8/25/2009
Use Column I on Contracts where variable retainage for line items may apply. PROJECT NO: 815
A 13 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)
I General Conditions $9,780.00 $0.00 $9,780.00 $0.00
2 5% Construction Management Fee $8,722.17 $958.30 $9,680.47 $0.'00
PAGE TOTAL $0.00 $18,502.17 $958.30 $0.00 $19,460.47 $0.00 $0.00
Users may obtain validation of this document by requesting of the license a completed AIA Document D401 Certification of Document's Authenticity
Arescribzd Gtr 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
�1 ors arSSJ� ✓���f� Purchase Order No.
S' St1 Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total S Sa' 3Q
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
Ord�
IN SUM OF
rl?/ P7��rs c Ur'��r,? �T
j oar
ON ACCOUNT OF APPROPRIATION FOR
Sa 2� �yG e, Y
Board Members
o Pr INVOICE NO. ACCT TITLE AMOUNT I hereby certify that the attached invoice(s), or
bill( is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
—I�V 20,--:Z9
Si gnature
Director of Operations
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund