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Home My WebLink About175781 08/06/2009 CITY OF CARMEL, INDIANA VENDOR: 362780 Page 1 of 1 ONE CIVIC SQUARE LITHKO CONTRACTING CARMEL, INDIANA 46032 PO BOX 270 CHECK AMOUNT: $20,416.76 MONROE OH 45050 CHECK NUMBER: 175781 CHECK DATE: 8/6/2009 DEPARTMENT ACCOU PO NUMBER INVOICE NUMBER A DESCRIPTION 902 4460805 4 20,416.76 RETAIL SITE #5 APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE ONE OF PAGES TO "'o..z:z PROJECT: CARMEL CITY APPLICATION NO: 4 Distribution to: CITY OF CARMEL, REDEVELOPMENT COMMISSIC CENTER PHASE 1 PERIOD TO: June 30, 2009 7OWNER 1 1 1 WEST AMIN ST., SUITE 180 PROJECT NOS: 7ARCHITECT CARMEL, IN 46032 LCI JOB# L5429 CONTRACTOR FROM CONTRACTOR: CHECK REMITTANCE ADDRESS: CONTRACT DATE: 8 LITHKO CONTRACTING, INC LITHKO CONTRACTING, INC. P.O. BOX 270 P.O. BOX 270 MONROE, OHIO 45050 MONROE, OHIO 45050 CONTRACT FOR: Place/Finish Concrete VIA ARCHITECT: CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, Application is made for payment, as shown below, in connection with the Contract. information and belief the Work covered by this Application for Payment has been Continuation Sheet, AIA Document G703, is attached. completed in accordance with the Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Certificates for Payment were issued and payments received from the Owner, and that current payment shown herein is now due. 1. ORIGINAL CONTRACT SUM 436,000.00 2. Net change by Change Orders 26,001.16 CONTRACTOR: LITHKO CONTRACTING, INC. 3. CONTRACT SUM TO DATE (Line 1 f 2) 462,001.16 4. TOTAL COMPLETED STORED TO 449,976.16 DATE (Column G on G703) By: Date: June 18, 2009 5. RETAINAGE: DREA GANNON, BILLING CO:QRDINATOR a. 10% of Completed Work 44,997.62 State of: OJ Y P (j" County of: WARREN 8. (Column° D E on G703) Subscribed and sworn to befoc�e t`i\' 1 .�181. �£'rC i of ABVC009 b. of Stored Material Z� (Column F on G703) Notary Public 1� 3 `rotary Public, State of Ohio Total Retaina e Lines 5a 5b or M Comm' sion i es: _n "fl Commission Expires g y 9 9 12 Total in Column I of G703) 44,997.62 ARCH ITECT' °I.F <i_ ATE °FORsPAYti PW Z t 42P 6. TOTAL EARNED LESS RETAINAGE 404,978.54 In accordance with the Contr1 pcurnents, based on on site observations and the data (Line 4 Less Line 5 Total) comprising the application, fil r- -ct certifies to the Owner that to the best of the 7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge, informatio an nd belief the Work has progressed as indicated, PAYMENT (Line 6 from prior Certificate) 384,561.78 the quality of the Work is in accordance with the Contract Documents, and the Contractor 8. CURRENT PAYMENT DUE 20,416.76 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH, INCLUDING RETAINAGE 57,022.62 (Line 3 less Line 6) AMOUNT CERTIFIED ?p t�.IMab CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explana n i amount c i ied differs from the amount applied. Initial all figures on this Total changes approved Application a d onth Cont' uatio Sheet that are changed to conform with -the amount certified.) in previous months b Owner $3,315.87 $0.00 ARCHITEC Total approved this Month $22,685.29 $0.00 By: Da wn TOTALS $26,001.16 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, payment and acceptance of payment are without NET CHANGES by Change Order $26,001.16 prejudice to any rights of the Owner or Contractor under this Contract. AIA DOCUMENT G702 -APPLICATION AND CERTIFICATION FOR PAYMENT 1992 EDITION AIA 01992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE., N.W., WASHINGTON, DC 20006 -5292 Users may obtain validation of this document by requesting a completed AIA Document D401 Certification of Document's Authenticity from the Licensee. JMP92 22 F Effective 1/31/01 Page 1 of 1 �F: CONTINUATION SHEET AIA DOCUMENT G/OJ• PAGE OF PAGES AIA Document 0702, APPLICATION AND CERTIFICATION FOR PAYMENT, containing APPLICATION NO: 4 Contractor's signed certification is attached. APPLICATION DATE: 6/18/2009 In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 6/30/2009 Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO: CARMEL CITY CENTER PHASE 1 Lo h ko L5429 CONTRACTING, INC. A B C D E F G H I ITEM DESCRIPTION OF WORK SCHEDULED WORK COMPLETED MATERIALS TOTAL BALANCE RETAINAGE NO. VALUE FROM PREVIOUS THIS PERIOD PRESENTLY COMPLETED (G C) TO FINISH (IF VARIABLE APPLICATION STORED AND STORED (C G) RATE) (NOT IN TO DATE D OR E) (D +E +F) 1 PAYMENT PERFORMANCE BOND 4,800.00 4,800.00 0.00 0.00 4,800.00 100% 0.00 $480.00 2 MOBILIZATION 5,000.00 5,000.00 0.00 0.00 5,000.00 100% 0.00 $500.00 3 GENERAL CONDITIONS LAYOUT 5,000.00 5,000.00 0.00 0.00 5,000.00 100% 0.00 $500.00 4 FIRESTOPPING 12,000.00 12,000.00 0.00 0.00 12,000.00 100% 0.00 $1,200.00 5 LIGHT POLE BOLLARD PEDESTALS 20,000.00 20,000.00 0.00 0.00 20,000.00 100% 0.00 $2,000.00 6 MOTOR COURT REBAR INSTALLATION 11,375.00 11,375.00 0.00 0.00 11,375.00 100% 0.00 $1,137.50 7 MOTOR COURT REBAR MATERIALS 38,500.00 38,500.00 0.00 0.00 38,500.00 100% 0.00 $3,850.00 8 MOTOR COURT PREP, PLACE FINISH 88,800.00 88,800.00 0.00 0.00 88,800.00 100% 0.00 $8,880.00 9 VETERANS WAY REBAR INSTALLATIO 6,500.00 6,500.00 0.00 0.00 6,500.00 100% 0.00 $650.00 10 VETERANS WAY REBAR MATERIALS 21,750.00 21,750.00 0.00 0.00 21,750.00 100% 0.00 $2,175.00 VETERANS WAY PREP, PLACE FINISH 49,600.00 49,600.00 0.00 0.00 49,600.00 100% 0.00 $4,960.00 HANOVER SQ REBAR INSTALLATION 6,500.00 6,500.00 0.00 0.00 6,500.00 100% 0.00 $650.00 HANOVER SQ REBAR MATERIALS 21,750.00 21,750.00 0.00 0.00 21,750.00 100% 0.00 $2,175.00 HANOVER SQ PREP, PLACE, FINISH 49,600.00 49,600.00 0.00 0.00 49,600.00 100% 0.00 $4,960.00 COURT PLAZA REBAR INSTALLATION 6,500.00 6,500.00 0.00 0.00 6,500.00 100% 0.00 $650.00 COURT PLAZA REBAR MATERIALS 21,750.00 21,750.00 0.00 0.00 21,750.00 100% 0.00 $2,175.00 COURT PLAZA PREP, PLACE FINISHI 49,600.00 49,600.00 0.00 0.00 49,600.00 100% 0.00 $4,960.00 RE MOB FOR CRANE AREA REBAR INSTALL 1,625.00 0.00 0.00 0.00 0.00 0% 1,625.00 $0.00 REMOB CRANE AREA REBAR MATERIALS 1 4,950.00 4,950.00 0.00 0.00 4,950.00 100% 0.00 $495.00 REMOB CRANE AREA PREP, PLACE, FINISH 10,400.00 0.00 0.00 0.00 0.00 0% 10,400.00 $0.00 CO #1 ASI #1 2 DRAWING REVISION 3,315.87 3,315.87 0.00 0.00 3,315.87 100% 0.00 $331.59 CO #2 ASI #3,. #4 ESI #16 CHANGES 22,685.29 0.00 22,685.291 0.00 22,685.29 100% 0.00 $2,268.53 GRAND TOTALS 462,001.16 427,290.87 22,685.291 0.00 449,976.16 97% 12,025.00 $44,997.62 Users may obtain validation of this document by requesting of the license a completed AIA Document D401 Certification of Document's Authenticity Page l of t JNIP92 -20 -F Effective- 1/31/01 L5429 WAIVER OF MECHANIC'S LIEN RIGHT BY SUPPLIER WHERE AS, the undersigned furnished materials and /or services to the insured development known as CARMEL CITY CENTER located at 101 City Center Drive, in the city of CARMEL county of HAMILTON state of INDIANA. WHERE AS, the undersigned desires to waive, release and quit -claim to Owner, all lien rights, including the right to file a notice of Mechanic's Lien or hereafter a Mechanic's lien upon the above described real estate to the extent for which the undersigned has received payment and to the extent permitted by the laws of the state of INDIANA NOW, THEREFORE, in consideration of the sum of One Dollar ($1,00) and other valuable consideration, receipt of which hereby acknowledge, the undersigned has hereby waived, released and quit -claim to Owner, (indicate either 1 or 2). 1. All lien rights as described above which it has or could have under the laws of the state of INDIANA to the date hereof for or on account of materials, appliances, machinery, fixtures, or furnishings, placed upon or installed on the above- described real estate. This waiver is effective upon receipt of Dollars 32,464.322. pril 30, 2009 2. All lien rights as described above which is has or could have under the laws of the state of INDIANA to the date hereof for or on account of materials, appliances, machinery, fixtures, or furnishings placed upon or installed on the above described real estate. This shall constitute a full and final waiver of the undersigned's rights to a Mechanic's Lien on the above- described real estate. DATED This Irk day of J(9 /V 201 Q 7 Ram Steel (Name of Supplier) (Name of Subcontractor) Lithko Contracting Inc. (Revised 10/2000 Signature) 1 Form Ap9rvved ��'�,`i�RAEN ®F CC)MPLI NCE Expims May DM9 mo. y 3 4, 1991 d'zn 7.143 q 3 Publle reporting burden for this collection of Information is estimated to average IG minutes per re-,Qome. i the time for revievving lmttvctlorn, scorching e data sources. gathering and maintaining thgge data needed, and completing and reviewing the collection of information. Send comments regarding this Barden estimate or any other aspect athfs collection OA Arlln onI Va22202�302t to theOfflce of Manngement Budget Paptrwor Reduction Projec ([)7pa -02 3 Washflnatona DC 2o503R�m 1215 ]ef4enon Davis k5ighrray. Suite 2. PAYROLL PAYMEA'T DATE (YY11RftADD) 3. CONTRACT NUMBER 4. DATE (YYMMOD) 9. PAVROt6 NUMBER 05/22/09 05/22/09` l 1, Karen Cole CPP Payrol l Manager do hereby state. (!Name of signatory party) (Title/ (1) That I pay or supervise the payment of the persons employed by L1 thk0 Con n�Q r r) on the Car 0 C that during the payroll period commencing on the 11th day of d ing or wroi's) May 7777 2 09 and ending 4lte 17 th day of May 7777 -20-09 ail- persons employed on said project have been paid the full weekly wages earned, that, no rebates. have been or wiil be Made either directly or indirectly to or on behalf of said Li thko Contracting, I from the full weekly wages earned by any person (co"McT.f .1 and that no deductions have been made either directly or indirectly, from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 SYat 948, 63 Stat 108, 72 Stay. 967; 76 Stay. 357; 40 U.S.C. 276r), and described below: FIT, Social Security, Medicare, State and local taxes where ap2licable and miscellaneous authorized deductions, (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work performed. prentices employed in the above p (3) That any ap beriod are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by. the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State; are registered with the Bureau of Apprenticeship. and-Training, United_ States Department of Labor. (4) That: .(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4(c) below. (b) MERE FRINGE BENEFITS ARE PAID IN CASH, Each laborer or mechanic listed in the above referenced payroll has been paid as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in section 4(c), below. (c) EXCEPTipki EXCEPTION (Craft) EXPLANATION S. REMARKS 6. NAME (Lash First RRiddle Initial) 7. TITLE B. SIGNATURE Cole, CPP, Karen Payroll Mana er The willful falsification of any of the above stateme= may subject the contractor or Subcontractor to civil or criminal proecc ion. See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code. Form 879, JUN 89 Previous editions are obsolete. I ®aaf67 1 SUBCONTRACTOR'S SWORN STATEMENT OF INDEBTNESS WAIVER OF LIEN STATE OF Indiana COUNTY OF Hamilton A7r QVt Being duly sworn upon his /her oath disposes and says that: 1. He /she i 5_-A LEAD (inserting sole proprietor, partner or corporate office held, as the case maybe), of Lithko Contracting hereafter called the "Subcontractor". He /she is over the age of twenty -one. He /she is authorized to make this affidavit on behalf of Subcontractor. 2. Subcontractor is the CowX.¢ETE Subcontractor for the construction of the development known as CARMEL CITY CENTER located in CARMEL (City), INDIANA (state), hereafter referred to as the "Development pursuant to the contract between the Subcontractor and Signature Construction, LLC, the General Contractor. 3. This affidavit is made for the express purpose of inducing Signature Construction, LLC, to make payment to Subcontractor of the invoice submitted herewith for labor and materials furnished pursuant to said Contractor. Upon receipt of said payment the Subcontractor hereby waives any lien rights to which Subcontractor is entitled for labor or materials furnished for the development to the date hereof. 4. Listed below are all suppliers or other persons who either has furnished or might furnish the Subcontractor with materials, appliances, machinery, fixtures or furnishing placed upon or installed on the development. Mark (X) in the appropriate column for EACH supplier listed. Place an (X) in column: 1) If a waiver of lien by supplier conditioned by payment of a specified amount is attached hereto. (In this case also show the amount owed the supplier). 2.) If a FULL (final) lien release has been signed and delivered to the General Contractor. 3.) If the initial delivery has not been made. S upplier List (Add list if necessary 1 1. Amount Owed 3 Ew S T5�1 u14tWc2 INGI uD�7� e� 3 #1 and 2 correspond to the same numbered choices on the waiver format. Signature Construction, LLC is hereby authorized to make payment to each such unpaid creditor either directly or by check jointly payable to Subcontractor and such creditor, as Signature Construction, LLC shall determine. 5. There are no bills, charges, costs or expenses for labor or material which could now or hereafter result in lien being filed against the Development or a claim being asserted against the General Contractor except the persons or businesses named in Paragraph 4 above. IN WITNESS WHERE OF, affiant has signed this document on behalf of the Subcontractor this day of SIwF 7N- 20 q (Authorized Representatr o ubcontractor) County of /rl.I�'a� State of -,J Subscribed and sworn to before me, a Notary Public in and for said County and State, This Day of r (Nota 4P (Print Nake) My Commission Expires: NOTARY SEAL MUST APPEAR ON THIS FORM. Explro 6 LAU Contracting, Inc. {513} 539 -4144 Remittance Address P.O. BOX 270 Emit 3 MONROE, OHIO 45050 CONTRACTING, INC. 149837 TO: CITY OF CARMEL, REDEVELOPMENT COMMISSION 111 WEST AMIN ST., SUITE 180 invoice No. CARMEL, IN 46032 25163 RI C/O SIGNATURE CONSTRUCTION, LLC. 720 THIRD AVE., S.W. invoice Date CARMEL, IN 46032 6/18/09 Job name: Lithko Job No. Customer Job No. P.O. No. CARMEL CITY CENTER PHASE :t L54 Description Amount DRAW# 4 GROSS 22,685.29 RET 2,268.53 20,416.76 JUD jun 1 91009 COMMUNICATIONS CONVEYED ON CHECK TENDERED STATING PAYMENT IN FULL AND /OR WAIVING OF- LIEN RIGHTS TO ANY EXTENT MUST BE SENT TO SELLER AS FOLLOWS: ATTN: ACCOUNTS RECEIVABLE DEPT., LITHKO CONTRACTING, INC. P.O. BOX 270, MONROE, OH 45050 Payment Terms 3o DAYS TOTAL AMOUNT DUE b 20,416.76 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 service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. ll Payee Li 0 �o �7�v�� cT lam Purchase Order No. �0 Dj oX 2 7� Terms ��oGj�'o��0 zISUSG Date Due Invoice Invoice Description Amount Date N umber (or note attached invoice(s) or bill(s)) Total ;ZO jIla -76 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. 1, ALLOWED 20 IN SUM OF ON ACCOUNT OF IATION FOR �l Board Members PO# or INVOICE NO. ACCT #!TITLE AMOUNT DEPT. 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 7 /5 200, Director. 0 4* U6 Title Cost distribution ledger classification if claim paid motor vehicle highway fund