167658 01/07/2009 CITY OF CARMEL, INDIANA VENDOR: 00351429 Page 1 of 1
ONE CIVIC SQUARE M.K. BETTS ENGINEERING INC
CARMEL, INDIANA 46032 PO BOX 2533 CHECK AMOUNT: $151,919.58
ANDERSON IN 46018 CHECK NUMBER: 167658
CHECK DATE: 1/7/2009
DEPARTMENT ACCOUN PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
654 R5023990 S10726 13 CORR 151,919.58 CONSTRUCTION
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APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOC UMENT 6702 (Instructions on reverse side) PAGE ONE Or PAGES
TO (OWNER): City of Carmel PROJECT: Blower /Electrical Modification APPLICATION NO: Thirteen Distribution to:
One Civic Square Contract 60 (13) lJ OWNER
Carmel, IN 46032 PERIOD TO: 11 30 08 ARCHITECT
CONTRACTOR
FROM (CONTRACTOR): VIA (,ARCHITECT): ARCHITECT'S C
M. K. Betts Engineering PROJECT NO: C
Contracting, Inc.
CONTRACT FOR: Invoice No. 07 -262. 13 CO NTRACT DATE:
App
CONTRACTOR'S APPLICATION FOR PAYMENT Continu Sh et,fAIA D ement G703 T attached be connection
G703 is with the Contract.
CHANGE ORDER SUMMARY 1. ORIGINAL CONTRACT SUM S 2,349 ,000.00
Change Orders approved in I ADDITIONS DEDUCTIONS 2. Net change by Change Orders 5 295,205
previous months by Owner 3. CONTRACT SUM TO DATE (Line 1 2) S 2, 644,205 .00
TOTAL 4. TOTAL COMPLETED STORED TO DATE S 2,168
(Column G on G703)
Approved this Month
5. RETAINAGE:
Number Date Approved a. 9'0 of Completed Work S
C04�1 $302,815.00 7,610.00 (Column D E on G703)
b. of Stored Material
(Column F on G703)
Total Retainage (Line 5a 5b or
TOTALS $302 7,610.00 Total in Column I of G703) S 132,210.25
Net thane by Change Orders $295,205.00 6. TOTAL EARNED LESS RETAINAGE S 2 ,036,293 .86
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) S 1,884
paid by the Contractor for Work for which previous Certificates for Payment were B. CURRENT PAYMENT DUE S 151 ,919 .58
issued and payments received from the Owner, and that current payment shown 9, BALANCE TO FINISH, PLUS RETAINAGE 5 607
herein is now due. (Line 3 less Line 6)
CONTRACTOR: M. K. Betts Engineering Contracting, Inc. State of: Indiana County of Madison
Subscribed and sworn to before me this 30t day of Nov'. 2008
Notary Public:,
By: a Date: November 30, 2008 My Commission expires: October 28 2015
AMOUNT ERTI ifa t ieddi fors f rom 5
ARCHITECT'S CERTIFICATE FOR PAYMENT PP
(Attach explanation ii amount certified differs from the amount a pp lied 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 j
best of the Architect's knowledge, information and belief the Work has progressed as By: I Date:
Z
indicated, the quality of the Work is in accordance with the Contract Documents, and This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
the Contractor is entitled to payment of the AMOUNT CERTIFIED. Contractcr named herein. Issuance, payment and acceptance of payment are without
prejudice to any rights of the Owner or Contractor under this Contract.
Al DOCUMENT 6772 \PP1 W.. AT1r wn rtgTlttr rn- o.,.•..c.:�
Prescribed by State Board of Accounts City Form No. 201 (Rev 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show, kind of service, where
performed, dates of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
351429
M.K. BETTS ENGINEERING CONTR Purchase Order No. Q;
P.O. Box 2533 Terms
Anderson, IN 46018 Due Date 12/29/2008
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
12/29/200 13 CORR $151,919.58
hereby certify that the attached invoice(s), or bill(s) is (are) true and
:orrect and I have audited same in accordance with IC 5- 11- 10 -1.6
Date Off'
,YJOUCHER 087007 WARRANT ALLOWED
351429 IN SUM OF
M.K. BETTS ENGINEERING CONTR
P.O. Box 2533
Anderson, IN 46018
Carmel Wastewater Utility
I
(PN ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
13 CORR 07- 1050 -61 $151,919.58
C' O NyPGf! y
<(P
Voucher Total $151,919.58
Cost distribution ledger classification if
claim paid under vehicle highway fund