HomeMy WebLinkAbout206842 02/28/2012 CITY OF CARMEL, INDIANA VENDOR: 354355 Page 1 of 1
ONE CIVIC SQUARE VALENTI HELD
O 755 W CARMEL DRIVE SUITE 207 CHECK AMOUNT: $12,077.00
CARMEL, INDIANA 46032
INDIANAPOLIS IN 46254 CHECK NUMBER: 206842
CHECK DATE: 2/28/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
2200 R4462000 25831 1 12,077.00 ILLINOIS ST WALL REPA
Application and Certificate For Payment Page 1
To Owner: CITY OF CARMEL Project: ILLINOIS STREE WALL RPR Application No: 1 Date: 02/17/2012
ONE CIVIC SQUARE P,O. #25831 Period To: 02/17/12
CARMEL, IN 46032 ILLINOIS STREET
CARMEL, IN 46032 Architect's 5
From Valenti -Held Cont. /Dev., Inc. Project No: �krJ
(Contractor): 755 W. Carmel, Drive Contractor Job 1129
Number: Contract Date: q
Suite 207 Carmel, IN 46032 Via (Architect): b
Phone: 317 769 -6922
Contract For:
Contractor's Application For Payment
Change Order Summary Additions Deductions Original contract sum 12,077.00
Change orders approved in
previous months by owner Net change by change orders 0.00
Date Contract sum to date 12,077.00
Number Approved
Change Total completed and stored to date 12,077.00
orders
approved Retainage
this month
0.0% of completed work 0.00
Totals 0,0% of stored material 0.00
Net change by change
orders Total retainage 0.00
The under sig d Contractor certifies that to the best of the Contractor's knowledge, Total earned less retainage 12,077.00
information, d belief the work covered by this Application for Payment has been completed in
accordance h the Contract Documents, that all amounts have been paid by the Contractor
for work f r hick previous Certificates for Payment were issued and payments received from Less previous certificates of payment 0,00
the O n nd tha curr payment shown herein is now due.
Current sales tax
Cont r ct
a 0.000% of taxable amount 0.00
B C x �t! Date:_ -Ll_._ TAX EXEMPT 30B
State of: county of: Current sales tax 0.00
Subscribed d sworn to before me this k day of Ali
Q0 td- (year Notary public t},ta,�de✓ Current payment due 12,0177.00
My commission expires 160-L .zoo. Balance to finish, including retainage 0.00
Architect's Certificate for Payment
In accordance with the Contract Documents, based on on -site observations and the data Arc itect:
comprising the above application the Architect certifies to the Owner that to the best of the
Architect's knowledge, information and belief the Work has progressed as Indicated, the quality B Date:
of the Work is in accordance with the Contract Documents, and the Contractor is entitled to
payment of the Amount Certified. Thi Certification is not negotiable. The Amount Certified is payable only to the Contractor named herein. Issuance,
payment, and acceptance of payment are without preiudice to any rights of the Owner or Contractor under this
Amount Certified:
Contract.
Application and Certificate For Payment page 2
To Owner: CITY OF CARMEL Application No: 1 Date: 02/17/12 Period To: 02/17/12
From (Contractor): Valenti -Held Cont. /Dev., Inc. Contractor's Job Number: 1129
Project: ILLINOIS STREE WALL RPR Architect's Project No:
Work Completed
Materials Completed and
Item Scheduled Previous Presently Stored Stored to Date Balance to Finish
Number Description Value Application This Pe Retenti M e m o
1000 ILLINOIS STREET WALL REPAIR 12,077.00 0.00 12,077.00 0.00 12,077.00 100.00 0.00 0.00
Application Total 12,077.00 0.00 12,077.00 0.00 12,077.00 100.00 0.00 0.00
z
AFFIDAVIT AND WAIVER OF LIEN
Final (X) Partial X Payment to Follow
State of Indiana, County of Boone, SS: Allen M. Valenti, being duly sworn states that he
is the Chief Executive Officer of VALENTI -HELD CONTRACTOR/DEVELOPER,
INC. having contracted with City of Carmel to furnish certain materials and/or labor as
follows:
Sitework AIA Document #1129 *01 Application #1
located at Illinois Street Wall Repair and owned by City of Carmel and does hereby
further state on behalf of the aforementioned business:
Partial Waiver that the balance due from the contractor is the sum of Twelve Thousand
Seventy Seven Dollars 00 /100 ($12,077.00),
receipt of which is hereby acknowledged; or
X the payment of which has been promised as the sole consideration for this
Affidavit and Partial Waiver of Lien which is given to and for said
amount, effective upon receipt of such payment;
Final Waiver that the final balance due from the contractor is the sum of
00 /100 dollars
receipt of which is hereby acknowledged; or
the payment of which has been promised as the sole consideration for this
Affidavit and Final Waiver of Lien which shall become effective upon
receipt of such payment.
THEREFORE, the undersigned waives and releases unto the Owner of said premises, any
and all lien or claim whatsoever on the above described property and improvements
thereon on account of Labor or material or both, furnished by the undersigned thereto,
and further certif that no other party has any claim or right to a lien on account of any
work performe o material furnished to the undersigned for said project, and within the
scope of this a i avit and waiver.
VALEN D C6NTRACTOR DEVELOPER INC.
Allen M. enti, Chief Executive Officer
WITNESS Y HAND AND NOTARIAL SEAL, this 17th day of February 2012.
Jacqueline S. Francescon
of ry Public Printed Name
My Commission Expires June 20, 2012. I am a resident of Marion County.
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
Valenti Held
Purchase Order No.
755 W Carmel Drive Ste 207
Terms
Indpls., IN 46254
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
2/17/12 1 Illinois Street Wall Repair $720.00
Total $720.00
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
Valenti HPId IN SUM OF
755 W Carmel Drive Ste 207
Indpls., IN 46254
$12,077.00
ON ACCOUNT OF APPROPRIATION FOR
Department of Engineering
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
25831 1 2200- R4462000 12,077.00 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
Signature
C��� E,no�ua a
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund