HomeMy WebLinkAbout174407 07/08/2009 a CITY OF CARMEL, INDIANA VENDOR: 362780 Page 1 of 1
0 ONE CIVIC SQUARE LITHKO CONTRACTING CHECK AMOUNT: $260,412.41
CARMEL, INDIANA 46032 PO BOX 270
4 _�o
MONROE OH 45050 CHECK NUMBER: 174407
CHECK DATE: 7/8/2009
DEPARTM ACC OUNT PO N UMBER I NVOIC E NUM BER AM OUNT DESCRIPTI
902 4460805 2 154,288.13 MOTOR COURT CONCRETE
902 4460805 3 106,124.28 CITY CENTER PHASE 1
APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENTG702 PAGE ONE OF PAGES
TO ONVNEZR: PROJECT: CARMEL CITY APPLICATION NO: 3 Distribution to:
CITY OF CARMEL, REDEVELOPMENT COMMISSIC CENTER PHASE 1 PERIOD TO: May 31, 2009 7OWNER
1 1 I WEST AMIN ST., SUITE 180 PROJECT NOS: F
CARMEL, IN 46032 LCI JOB# L5429 CONTRACTOR
FROM CONTRACTOR: CHECK REMITTANCE ADDRESS. CONTRACT DATE: e
LITI-IKO 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 3,315.87 CONTRACTOR: LITHKO CONTRACTING, INC.
3. CONTRACT SUM TO DATE (Line 1 t 2) 439,315.87
4. TOTAL COMPLETED STORED TO 427,290.87
DATE (Column G on G703) By: Date: May 19, 2009
5. RETAINAGE: A DREA GA I Qt2DINjYT9MN1 A BUCH
a. 10% of Completed Work 42,729.09 State of: O r ��outyLF2fc, StaWARU2FAI
(Column D E on G703) Subscribed and sw rnlnis:day n esMay, 2009
b. of Stored Material 19, ?%12
(Column F on G703) Notary Public: T? r1,, 1 8 2F
Total Retainage (Lines 5a 5b or My Commission expire T` v
Total in Column I of G703) 42,729.09 ARCHITEC S CERTIFICATE FOR PAYMENT
6. TOTAL EARNED LESS RETAINAGE 384,561.78 In accordance with the Contract Documents, based on on site observations and the data
(Line 4 Less Line 5 Total) comprising the application, the Architect certifies to the Owner that to the best of the
7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge, information and belief the Work has progressed as indicated,
PAYMENT (Line 6 from prior Certificate) 278,437.50 the quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE 106,124.28 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE 54,754.09
(Line 3 less Line 6) a� AMOUNT CERTIFIED
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation f amount certified differs from the amount applied Initial all figures on this
Total changes approved Application and he Continuation Sheet that are changed to conform with the amount certified)
in previous months by Owner $0.00 $0.00 ARCHITECT ;kj
Total approved this Month $3,315.87 $0.00 By: L(2 Da 3,/Z�Io9
TOTALS $3,315.87 $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 $3,315.87 prejudice to any rights of the Owner or Contractor under this Contract.
'r 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.
HAP92 -22 -F Effective- 1/31/01
Page I of 1
CONTINUATION SHEET AIA DOCUMENT G703 PAGE OF PAGES
AIA Document 0702 APPLICATION AND CERTIFICATION FOR PAYMENT, containing APPLICATION NO: 3
Contractor's signed certification is attached. APPLICATION DATE: 5/19/2009
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 5/31/2009 n
Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO:
CARMEL CITY CENTER PHASE i L
L54 29 CONTRACTING, INC.
A B C D E F G FI 1
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 4,000.00 1,000.00 �1Z 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 0.00 88 ,800.00 Qc o 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 1 0.00 21,750.00 100% 0.00 $2,175.00
VETERANS WAY PREP, PLACE FINISH 49,600.00 24,800.00 24,800.00 .��2 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 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 0.00 3,315.87 0.00 3,315.87 100% 0.00 $331.59
0.00 0.00 0.00 0.00 0.00 0% 0.00 $0.00
GRAND TOTALS 439,315.87 309,375.00 117,915.87 0.00 427,290.87 97% 12,025.00 1 $42,729.09
Users may obtain validation of this document by requesting of the license a completed AIA Document D401 Certification of Document's Authenticity
Page 1 of 1 JMP92 -20 -F Effective- 1/31/01
SUBCONTRACTOR'S SWORN STATEMENT OF
INDEBTNESS WAIVER OF LIEN
STATE OF Indiana
y C OUNTY milton
�Q Being duly sworn upon his /her oath disposes and
says that:
1. He /she i km N"A" (inserting sole proprietor, partner or corporate office held, as the case maybe),
of Lithko Contractinq 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 Cc/JCZ.F_tf_ 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. A mount Owed 3
o r�wu�v�t s 44 7 47.E eo)u &w GAS v> aer� P IN
#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 o half of the Subco actor this
day of 0-n{
(Authorized Representative of Sub ntractor)
County of 4MAtLTon
State 0 f7f, *,AJA
S dlan o before me, a Notary Public in and for said County and State,
S*6 01
's
m (N tary Public)
10tow X_
G (Printed Name)
's on
N APPEAR ON THIS FORM. (Revised 10/2000 Signature)
6
1
i 1
Lithko Contracting, Inc.
{513} 539 -4144
Remittance Address s
P.O. BOX 270
MONROE, OHIO 45050 I tCO N T R ACT I N G, I Id C.
149837
TO: CITY OF CARMEL, REDEVELOPMENT COMMISSION
111 WEST AMIN ST., SUITE 180 invoice No.
CARMEL, IN 46032 25032 RI
C/O SIGNATURE CONSTRUCTION, LLC.
720 THIRD AVE., S.W. invoice Date
CARMEL, IN 46032 5/19/09
Job name: Lithko Job No. Customer Job No. P.O. No.
CARMEL CITY CENTER PHASE i L54
Description Amount
DRAW# 3 GROSS 117,915.87
RET 11,791.59
106,124.28
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 go DAYS TOTAL AMOUNT DUE b 1061 124.28
LETTER OF TRANSMITTAL
DATE: May 19, 2009 CONTRACTING, IPiC,
TO: CITY OF CARMEL, REDEVELOPMENT COMMISSION
ill WEST AMIN ST., SUITE 18o
CARMEL, IN 46032
ATTN: ACCOUNTS PAYABLE
RE: CARMEL CITY CENTER PHASE 1
We are Sending You The Following Items Via: FED EX
Contract El Proposal Billing Documents Tax Exempt Certificate
Final Waiver of Lien 0 Affidavit Change Order Certificate of Insurance
Waiver ❑X Invoice Subcontract Workers Comp. Certificate
COPIES DATE PROJECT DESCRIPTION
5/19/2009 CARMEL CITY CENTER DRAW 3
These are transmitted for the following Disposition:
For Approval Approved QX Payment
For Your Files F Complete and Return
❑X As Requested F-1 Returned for Record Set
Remarks:
Copies To: L5429
ANDREA GANNON, BILLING COORDINATOR
{5 539 4 1 6 2
P.O. BOX 270
MONROE, OH 45050
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
I-Ak o Co 'troc'7 A Purchase Order No.
Terms
/V oc�t �JG� �fSUSd Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
r
ra. 1 V
w�
u_
F of
Total
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in acc ordance
with IC 5- 11- 10 -1.6. C
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
14 L L IN SUM OF
d 270
ON ACCOUNT OF APPROPRIATION FOR
4L�l z 19 5
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
902, &)6 4- 12 1 1, 28 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
200
Si ture
Dlrea r of Operatior s
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
Cithko' Contracting, Inc.
{513} 539 -4144
Remittance Address
P.O. BOX 270 h,
MONROE, OHIO 45050 CONTRACTING, INC.
149837
TO: CITY OF CARMEL, REDEVELOPMENT COMMISSION
111 WEST AMIN ST., SUITE 180 Invoice No.
CARMEL, IN 46032 24913 RI
C/O SIGNATURE CONSTRUCTION, LLC.
720 THIRD AVE., S.W. Invoice Date
CARMEL, IN 46032 4/17/09
Job name: Lithko Job No. Customer Job No. P.O. No.
CARMEL CITY CENTER PHASE 1 L54
Description Amount
DRAW# 2 GROSS 171,431.25
RET 17,143.13
154,288.13
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 S 154,288.13
APPLICATION AND CERTIFICATION FOR PAYMENT AIADOCUMENTG702 PAGE ONE OF PAGES
TO r' AENE PROJECT: CARMEL CITY APPLICATION NO: 2 Distribution to:
CITY OF CARMEL, REDEVELOPMENT COMISSION CENTER PHASE I PERIOD TO: April 30, 2009 OWNER
11 I WEST MAIN ST., SUITE 180 PROJECT NOS: ARCHITECT
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 0.00 CONTRACTOR: LITHKO CONTRACTING, INC.
3. CONTRACT SUM TO DATE (Line I f 2) 436,000.00
4. TOTAL COMPLETED STORED TO 309,375.00
DATE (Column G on G703) By: Date: April 17, 2009
5. RETAINAGE: DR A GANNON, BI LI G COORDINATOR
a. 10% of Completed Work 30,937.50 State of. OHIO Y P� County of: WARREN
(Column D E on G703) Subscribed and sworn to befor 'el�his 17 day of Aq� �'1� 009
Z
b. of Stored Material °°f' �°5 "�IVi
(Column F on G703) Notary Public: Public, Slate of Ohio
Total Retainage (Lines 5a 5b or My Commis ion ires: a „"nisi °n Expires
Total in Column I of G703) 30,937.50 ARCHITECT TfFICA►TE FOR PAYfUIBUT�a2
6. TOTAL EARNED LESS RETAINAGE 278,437.50 In accordance with the ContracD,o Yme t ;fba`sed on on -site observations and the data
(Line 4 Less Line 5 Total) J comprising the application, the'. A�r,&ite 'ct��tifies to the Owner that to the best of the
7. LESS PREVIOUS CERTIFICATES FOR r: Architects knowledge, inform un-U belief the Work has progressed as indicated,
PAYMENT (Line 6 from prior Certificate) y 124,149.37 the quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE 154,288.13 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE 157,562.50
(Line 3 less Line 6)
j AMOUNT CERTIFIED I V4; M.
CHANGE ORDER SUMMARY ADDITIONS' 1 DEDUCTIONS (Attach explanati if amount certified differs from the amount applied. Initial all figures on this
Total changes approved 1 ;;t1 Application a o the Continuation Sheet that are changed to conform with the amount certified)
in previous months by Owner =$0.00 $0.00 ARCHITEC
Total approved this Month $0.00 $0.00 B Da
TOTALS $0.00 $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 $0.00 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 I
CONTINUATION SHEET AIA DOCUMENT G703 PAGE Or PAGES
AIA Document G702, APPLICATION AND CERTIFICATION FOR PAYMENT, containing APPLICATION NO: 2
Contractor's signed certification is attached. APPLICATION DATE: 4/17/2009
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: 4/30/2009
Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO:
CARMEL CITY CENTER PHASE 1 [mthko
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 4,000.00 1,000.00 0.00 5,000.00 100% 0.00 $500.00
3 GENERAL CONDITIONS LAYOUT 5,000.00 3,000.00 1,000.00 0.00 4,000.00 80% 1,000.00 $400.00
4 FIRESTOPPING 12,000.00 9,600.00 2,400.00 0.00 12,000.00 100% 0.00 $1,200.00
5 LIGHT POLE BOLLARD PEDESTALS 20,000.00 5,000.00 15,000.00 0.00 20,000.00 100% 0.00 $2,000.00
6 MOTOR COURT REBAR INSTALLATION 11,375.00 2,843.75 8,531.25 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 0.00 0.00 0.00 0.00 0% 88,800.00 $0.00
9 VETERANS WAY REBAR INSTALLATIO 6,500.00 0.00 6,500.00 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 0.00 24,800.00 0.00 24,800.00 50% 24,800.00 $2,480.00
HANOVER SQ REBAR INSTALLATION 6,500.00 0.00 6,500.00 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 0.00 49,600.00 0.00 49,600.00 100% 0.00 $4,960.00
COURT PLAZA REBAR INSTALLATION 6,500.00 0.00 6,500.00 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 0.00 49,600.00 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 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
0.00 0.00 0.00 0.00 0.00 0% 0.00 $0.00
0.00 0.00 0.00 0.00 1 0.00 0% 0.00 $0.00
GRAND TOTALS 436,000.001 137,943.75 171,431.25 0.00 309,375.00 71% 126,625.00 $30,937.50
Users may obtain validation of this document by requesting of the license a completed AIA Document D401 Certification of Document's Authenticity
Page I of 1 JMP92 -20 -F Effective- 1/31/01
SUBCONTRACTOR'S SWORN STATEMENT OF
INDEBTNESS WAIVER OF LIEN
STATE OF Indiana
COUNTY OF Ham
/�7LQ� Being duly sworn upon his /her oath disposes and
says that:
1. He /she is A (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 Cctx F_(R- 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 2 3
'(Tel s (,5 5�
C tOAZ 4 zq Z
#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 A t, 1 6 1 tt 20
(A thori ed epresentatige of u6contractor)
County of I ILTW
State of (,jAlVA
Subscribed and sworn to before me, a Notary Public in and for said County and State,
This 0 201K I° .:hl 20 G5
(No ary Public)
if of (Printed Name)
S
My Comm s:
NOTARY S IS FORM. (Revised 10/2000 Signature)
6
Form .approved
OM8 hro. 070x4213
STATEMENT OF COMPLIANCE expires Msy3r, rase
O
burden for this wAecdon of I t
in 1:: if estlmmd to average re mimrtes pet response. IrKruding the time foe wtnxtiom, searching ex
data sources,
N Alt reporting (s q
gathering and maimalning th needed, u and mmpreting and mitwrnq the mllectlan of Intarmatlon. Send tammenttregardingthls burden esttnsace of any other aspect ai this mtteNon
Ct Intormatlon, VA 722x2- ]02� 'r
and to QHn t den, sh n e Man Wa d d get. work Re t ctfcn roject (C
P
data 770"213L W"htngtona C `'0 0 R�� 73151ettenon Oavh Nfghv,e7. Suite
t206,arUnq on, i 4. DATE MM7
1. PAYROLL NUMBER 2 LL AYMEN ATS
O (YYitdMDO) CONTRACT NUMBER
PAYRO D
V Payroll Mana4er do hereby state.
I, Karen Cole CPP Rrd
QYame or d ry gnato parry!
(1) That i pay or supervise the payment of the persons em lop_ yed by Li t hko Cont�a n r
an the �ll���\ /�s during the payroll period commencing on the 1 t Q day of
faiardrnq +,e all persons
2 0 o J and ending the aay of 1 �W� 2D
employed on said projecthave been paid the full weekly wages 'earned, that,no .rebates. have been or will be made either directly or indirectly
from the full weekly. wages earned by any person
to or on behalf of said Lithko Contracting, Inc.
(Contractw or p bm iraetor)
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 tabor under the Copeland Act as amended (48
Stat 948, 63 Stat 708, 72 Star 967, 76 Stat 357; 40 USG 276c), and described below:
FIT, Social Security, Medicare, State and local taxes where applicable 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 detefnrinaticn
incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work performed.
bona fide apprenticeship program registered with a
(3) That any apprentices employed in the above period are duly registered in a
State apprenticeship agency recognized by, the Bureau of Apprenticeship and Training. United 5tates Cepartment 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 benefrts 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) WHERE FRINGE BENEFITS ARE PAID IN CASH,
�qy Each laborer or mechanic listed in the above referenced payro ll 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) EXCEP770td5
EXCEPTION (Craft) EXPtANAT1ON
S. REMARKS
6. NAME (Las Middle Initial) 7. TfTLE 8. SIGNATURE
t: Finr
Cole CPP Karen Payroll Mg er C -rte /'r
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or cdeninal prosecvtron.
See Section 1007 of Title 18 and Sectlon 237 of Title 31 of the United States Code.
toasrtc7
DD Form 879, JUN 89 Previous editions are obsolete.
e
roan ,approved
oma No. 071744273
STATEMENT OF COMPLIANCE E,.;Wm May 37, J ssz
PuClle reporting Carden tar thb collection of Intormat7on is estimated to average 78 minutes per response. Indv `rte time for rer7ewrnq
ng the calle InatruRSoees. n earrhlnq existing dots sawca.
CA and maintatning t h e data needed, and completing and reviewing of Jnformat7o S end comments regarding that harden estimate or any other aspect ar this colect
O ov I ducig
dto' renofManden ,totyandnuudget.PB ev+orRSCduRonP�ro(ea(0704.023 washfnatan. tDC2p503Re0or�. 1215Je?ierwnOavlsN7gh.+ay,Suite
2. PAYROLL PAYMEl�'T DATE L 31CO N TRACT NUMBER 4BATE (YYJWJ40D)
t. PAYROLL NUMBER 04/03/09 04/03109
CPP Pa roll Mana er do hereby state.
i, Karen Cole, R ;rJe
(ivama or slgnoeary party) J
(t) That I pay or supervise the payment of the persons employed by L
on th e �6 p/11 tha during the payroll period commencing on t h e 23rd day of
(auad or work)
March 2 n 09 and ending the 29t day of March Z 09 all persons
earned. that.no.rebates,have been or will be made either directly or indirectly
ernpioyedon said pro;ecthave been Paid thefull weekly wages
from the full weekly wages earned by any person
to or an behalf of said Li thko Contracting, Inc.
(ConerxYor or al6mntza
and that no deductions have been made either directly or indirectly, from the full wages earned by any pers on, other than permissibl
as amended (4 8
deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland
Act
Seat 946, 63 Seat; yob, 72 Stae 967; 76 Stay. 357, 40 U..S:C 276c), and described below:
FIT Social Security, Medicare, State and local taxes where applicable 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.
(3) That any apprentices employed in the above period 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 Stares 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) WHERE FRINGE BENEFITS ARE PAID IN GASH,
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) EXCl:PTiOAIS
EXCEPTION (Craft) EXPLANATION
S. REMARKS
6. 14AMS (Las? Frrs� Middle initial) 7. 'TITLE a. 51G g ATURE
Cole, C_PP, Karen Payroll Manager
The wrifful falsif7cation of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution
-See Section loot of Title la and Section 231 of Title 31 of the United States Code.
10861167
®D Form 1379, JUN 89 Previous editions are obsolete.
Fav,M Apprvred
STATEMENT OF COMPLIANCE Expl Mm o 70a -02rd
apfres htaq 31, r942
PvWtc reporting burden for this cottectiort of Iniormatlon is ertlmated to average 16 minutes pet resFOnse, tnrtudlrg Site time for revtextng Instructions
seorthing a :lsting dots vo�rcet.
getherfag and maintstntng the data needed, and tampletln and rerierotng the collerJon of trAormatton. SeM matmene' regar that burden Ins tmate or any other aspect Of thfs wlEectlon
or Informatio Including t darn to the ducing his bur n, to a shing PapEn� I Reduction Project (070a-021 information ashlnat operations
n, t nC i0503
Retorts. 1215 Jefferson t)avfs Highway. Suite
1204. gt 'd t Bu dge
4. DATE (rYMMOO)
t. PAYROLi. NUMBER 111 2. PAYROLL PAYMENT DATE (YYMMDD) 3. CONTRACT NUMZER 04/10 09
f� 04/10/09 1
do hereby seate.
1, Karen Cole CPP Pa roll Mana er
(Name of Signatory party) n da
(t) That I pay or supervise the payment of the persons employed by Li thko Contracts nq, I ns
(Cantrxclor or wbronurrstor)
c. eye r R 'that 30th da en the l�1rn� during the payroll period commencing on the Y of
(Budd! fig or wort)
March 2 and ending the 5th day of April 2�J 09 all persons
empibyed on said projecthave been Raid the full weekly wages'earned, that.,no .rebates. have been or will be made either directly or indirectly
to or on behalf of s$id Li thko Contracti Inc. from the full vbeekly wages earned by any person
(Contractor or ,pnoxctnr)
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
Star 948, 63 Stat: fog, 72 Stat 967; 76 Star. 357; 40 U.S.0 2764, and described below:
FIT Social Security, Medicare, State and local taxes where applicable 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 determinaticr
incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period 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) WHERE FPJNGE BENEFITS ARE PAID iN CASs
Each laborer or mechanic listed in the above referenced payroll has been paid as indicated on the payroll, an amount not less
Eg 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) EXCEPTiok1
EXCEPTION (Craft) EXPLANATION
5. REMARKS
6. NAME (Cass~ Firs#, Middle lnitiaQ 7. -TITLE 8. SIGNATURE-
Cole, CPP,, Karen Payroll Manager
The w171ful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution.
See Section fool of Tide le and Section 231 of Title 31 of the United States Code.
DD Form 879, 11111) 89 Previous editions are obsolete. °a5r15�
t o
4
Form Approved
OA48 M4 070x4273
0. STATEMENT OF COMPLIANCE Espfres May 37. 1992
Pvbik reporting burden tot tlth collect on of Irttarmatlon s �tlmated to P average tG minutes per response. Including the time fat reviewing Instruction searching eslsdng data llit It s,
gathering and maintaining the data needed, and completing and reviewing the collection of Iniornation. Send command regarding this burden estimate Or any other aspect of IM collectbn
ofintoi mutton, Indudmgsugggesdomforredudngthisbur den. to Washin gtonHe� +rt��ices w D< 20n 00M. 12t5leftersonDavhHlgh.+ay.Suite
120 Atlington, VA 22202 02. and to the office of Manngemers Budg and t. h Reduction Project (070x- 0113), DA AAMDO
1. PAYROLL 14UMBER 2. PAYROLL PAYMENT DATE (YYM)4iDD) 3. CONTRACT NUMBER
04117/09 T 04117109
Payroll Manager do hereby state.
i, Karen Cole CPP (Tide)
(Name oP signatory party)
(t) That I pay or supervise the payment of the persons employed by L1 thk0 Con ��dCtfP�C1 no
an the �rrnm 1�r
OrV t- �E�ai"`� during the payroll period commencing on the 6th day of
(lhdtd[ er
April 2109 and ending the 12th day of April 09 all persons
emplbyed on said project have been paid the full weekly wages'earlled, tha4,no .rebates. have been or will be tirade either directly or indirectly
ko Contracts r
from the full vveekfy, wages earned by any person
to or on behalf of said Li th
(Contracto at svlrasnaacror)
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
Stat 948, 63 Stat 108, 72 Stat. 957, 76 Stat 357; 40 USG 176c), and described below-:
FIT, Social Security, Medicare, State and local taxes where appli and
miscellaneous authorized deductions,
(2) That arty payrolls otherwise under this contract required to be submitted for the above period are correct and wlnPlete; that the
wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determinaticn
incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a
State apprenticeship agency recognized by, the Bureau of Apprenticeship and Training, United 5tates Department of Labor, or if no such
recognized agency exists a State; are registered with the Bureau of Apprenticeship.and_.Training, United_States,.Qepartment of Labor.
(4) That:
.(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS
[n addition 4o 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) WHERE 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) EXCEP770A15
EXCEPTION (Craft) EXPLANATION
5. REMARKS
0 6. NAME (Las', First, iNiddle lnitfa0 7. -TITLE 8. SIGNATURE-
Cole, CPP, Karen Payroll Mana erg
The willful falsi{cadon of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution.
See Section 1001 of Title la and S4:ctiori 231 of Title 31 of the United States Code.
DD form 879, JUN 89 Previous editions are obsolete. ioad157
VOUCHER NO. WARRANT NO.
ALLOWED 20
p Ko C C o, 7✓Q, 7 e /h"
IN SUM OF
/yc n t,' 0 0�j 0
ON ACCOUNT OF APPROPRIATION FOR
z/�yGG (?o_S
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
91J2 2 yy6��os
15 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
5 4 200
Signature
®irector of Operations
)n ledger classification if Title
or vehicle highway fund
Prescribed by State Board of Accounts City Form No.
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.
Payee
L i��`LjkO Cg,-77 '4eT, (_I I n" Purchase Order, No.
s �JUiY 2 70 Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
F f CU e Pip s
Total ,1
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
IN SUM OF
IVo17 V' el 1 04 o
ON ACCOUNT OF APPROPRIATION FOR
qe, zj,yV66- R05
Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
91J2 2 y 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
200
Signature
Director of Operations
�n ledger classification if
Title
a�� or vehicle highway fund
u 'tk3