171024 04/16/2009 CITY OF CARMEL, INDIANA VENDOR: 361087 Page 1 of 1
ONE CIVIC SQUARE OLD NATIONAL TRUST CO
CARMEL, INDIANA 46032 ATfN: DAVID CROW CHECK AMOUNT: $4,500.00
1 MAIN STREET- 3B CHECK NUMBER: 171024
EVANSVILLEIN 47708
CHECK DATE: 411612009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
853 5023990 RETAINAGE 4,500.00 RETAINAGE
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To: Carmel/Clay Board of Parks and Recreation Project: Monon Family Recreation Center Application 23
760 3rd Avenue, S.W., Suite 100
Carmel, Indiana 46032 Contract For: BP 4 MC Electrical Application Date: 1/26/2009
Gaylor Job 1252530 Period Ending: 1/31/2009 YV'P'�
From: Gaylor, Inc. 91073701
17225 Kraft Court Architects r U
el 2 r 2009
Noblesville, IN 46060 General Contractor !d
APPLICATION FOR PAYMENT
Application is made for Payment, as shown below, in connection
CHANGE ORDER SUMMARY with the Contract. A Continuation Sheet, with a Schedule of Values
breakdown, is attached.
TOTAL CHANGE ORDERS APPROVED
ON PREVIOUS APPLICATIONS ADDITIONS DEDUCTIONS 1. ORIGINAL CONTRACT SUM $2,998,700.00
CHANGE ORDER DATE APPROVED 2. Net change by CHANGE ORDERS $487,111.00
Change Order 01 $11,934.00
Change Order 03 4,000.00 3. CONTRACT SUM TO DATE $3,485,811.00
Change Order 04 35,158.00
Change Order 05 254,672.00 4. TOTAL COMPLETED STORED TO DATE n $3,445,771.00
Change Order 06 Change Order 07 8,676.00 $1 5. RETAINAGE: l o re� flwt c) f4-)
I S
Change Order 08 11,233.00 IN I
Change Order 09 1,807.00 10.00% of completed work $4,500.00
Change Order 10 37,704.00 1/
Change Order 11 9;782.00 0.00% of stored material $0.00 4 ((CY /C f"
Change Order 12 37,634.00
Change Order 13 14.400.00 TOTAL RETA€ NAGE $4,500.00
Change Order 14 85,040.00
6. TOTAL EARNED LESS RETAINAGE $3,441,271.00
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT.. $3,400,771.00
8. CURRENT PAYMENT DUE.......... Y F $40,500.00
9. BALANCE TO FINISH, PLUS RETAINAGE........._.... $44,540.00
TOTALS: 500,106.00 $12,995.00
NET CHANGE BY CHANGE ORDERS: $487,111.00
The undersigned Contractor certifies that to the best of the Contractors knowledge, the State of: Indiana
Work covered by this Application for Payment has been completed in accordance with County of: Hamilton
the Contract Documents and that current payment shown herein is now due.
f Subscribed and sworn to before me this 26.00 day of
_Jan 2,009.00
Notary Public:
C R. Ginn uzzi
By: Date: 26- Jan -09 l
Name: Andrew Foreman My Commission expires on: 09/13116
Title: Project Manager
County of Residence: Hamilton
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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
Purchase Order No.
Old National Trust Company Terms
z
Attn: David Crow
1 Main Street 3B
Evansville, IN 47708
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
1126109 23 Escrow payment for Gaylor pay application 23 4,500.00
Total 4,500.00
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.
Old National Trust Company Allowed 20
Attm David Crow
tI 1 Main Street 3B
Evansville, IN 47708 In Sum of
4,500.00
ON ACCOUNT OF APPROPRIATION FOR
853 Gift Fund
PO# or INVOICE NO kCCT #/TITLI AMOUNT Board Members
Dept
853 23 5023990 4,500.00 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
9 -Apr 2009
Signature
4,500.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund