174416 07/08/2009 CITY OF CARMEL, INDIANA VENDOR: 00351429 Page 1 of 1
ONE CIVIC SQUARE M.K. BETTS ENGINEERING INC CHECK AMOUNT: $132,210.25
CARMEL, INDIANA 46032 PO BOX 2533
ANDERSON IN 46018 CHECK NUMBER: 174416
CHECK DATE: 7/8/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
659 5023990 19 132,210.25 1050.61
APPLICATION AND CERTIFICATE FOR PAYMENT A/A 000UJ%4ENr C702 (Instructions on reverse sides P1.c.E OF P \CES
TO (OWNER): City of Carmel. PROJECT: Blower /Electrical- Modification APPLICATION NO: Nineteen(19i�tributicw to:
One Civic Square Contract 60 Retainage C OWNER
Carmel., IN 46032 PERIOD TO: 05 -22 -09 C ARCHITECT
C CONTRACTOR
FROM (CONTRACTOR): VIA (ARCHITECT): ARCHITECT'S C
111. K. Betts Engineering PROJECT NO: C
Contracting, Inc..
CONTRACT FOR: Invoice No. 07- 262. Ret. CO NTRACT DATE:
is mae CONTRACTOR'S APPLICATION FOR PAYMENT Contin uat n Sheet, Document G703niss alt cheClconnection with the Contract.
CHANGE ORDER SUNVAARY 'I. ORIGINAL CONTRACT SUM 5 2, 349,000.00
I 2. Net change by Change Orders 337,584.58
Change Orders approved in ADDITIONS DEDUCTIONS
previous months by Owner 3. CONTRACT SUM TO DATE (Line 1 2) ,686 584.
TOTAL 4. TOTAL COMPLETED STORED TO DATE 2 686 584.58
Approved this Month (Column G on G703)
Number Date Approved 5. RETAINAGE:
C0111 a. of Completed Work
$302 815.00 7,610.00 (Column D E on G703)
CO#2 67,282.00 $18,140.00 b. o of Stored Material
CO#3 10,685.00 $17,447.42 (Column F on G703)
Total Retainage (Line 5a 5b or
TOTALS $380,782.00 $43,187.42 Total in Column I of G703)
Net change by Change Orders $337,584.58 6. TOTAL EARNED LESS RETAINAGE 2,686,584.58
The undersigned Contractor certifies that to the best of the Contractor's knowledge, (Line 4 less Line 5 Total)
information and belief the Work covered by this Application for Payment has been 7. LESS PREVIOUS CERTIFICATES FOR
completed in accordance with the Contract Documents, that all amounts have been PAYMENT (Line 6 from prior Certificate) 2,554,374.33
paid by the Contractor for Work for which previous Certificates for Payment were 8. CURRENT PAYMENT DUE 5 132,210.25
issued and payments received from the Owner, and that current payment shown 9, BALANCE TO FINISH, PLUS RETAINAGE —0
herein is now due. (Line 3 less Line 6)
CONTRACTOR: M. K. Betts Engineering Contracting, Inc. State of: Indiana Countv of: Hadison
Subscribed and sworn to before me this 22nd day of May 200
Notary Public:���__
Bv: Date: May 22, 2009 My Commission expires: October 28 201.5
ARCHITECT'S CERTIFICATE FOR PAYMENT AMOUNT CERTIFIED....:. b
m
(Attach explanation if aount t cer cer tified ied d rers f from t he amount applied for)
In accordance with the Contract Documents, based on on -site observations and the ARCHITECT:
data comprising the above application, the Architect certifies to the Owner that to the _•�G
best of the .-architect's knowledge, information and belief the Work has progressed as Bv: Date: 3
indicated, the quality of the Work is in accordance with the Contract Documents, and This Certificate is not negotiable. The ANIOUNT CERTIFIED is payable only to tt
the Contractor is entitled to payment of the AMOUNT CERTIFIED. Contractcr named herein. Issuance, payment and acceptance of payment are withov
prejudice to any rights of the Owner or Contractor under this Contract.
AIA DOCU.ti 0 0702 I'IC -N. NF) CERTIFI(. �Tf. FOR PAVr.1EXI .�I:�1' NA -AI A' c 1981
IFiE
�It
Form No. be
,rid -S (eBoRev. 1995) counts ACCOUNTS PAYABLE VOUCHER
Form 301 1995)
TO
ADDRESS
Invoice Date Invoice Number Item Amount
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
19
Signature Title
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.
1 19
icer Title
Voucher No. Warrant No.
f ACCOUNTS PAYABLE DETAILED ACCOUNTS
SANITATION DEPARTMENT ACC.
NOT
CARMEL, INDIANA
MR RP H 5 Favor Of
Total Amount of Voucher
Deductions
I
o 7.10 so G 13 22t o 5
Amount of Warrant
Month of 19
Acct.
VOUCHER RECORD No.
Collection System
Operation
Plant
Commercial
General
Undistributed U
Construction
Depreciation Reserve
Stock Accounts Merchandise
Total
Allowed
Board Members
Filed
BOYCE FORMS SYSTEMS 1- 800 382 -8702 325