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Home My WebLink About206842 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