170968 04/16/2009 CITY OF CARMEL, INDIANA VENDOR: 362780 Page 1 of 1
ONE CIVIC SQUARE LITHKO CONTRACTING
CARMEL, INDIANA 46032 PO BOX 270
CHECK AMOUNT: $124,149.38
rp MONROE OH 45050 CHECK NUMBER: 170968
CHECK DATE: 4/16/2009
DEPART A PO NUMB INVOICE NUMBER AMOUNT DESCRIPTION
902 4460805 1 124,149.38 RETAIL SITE #5
APPLICATION AND CERTIFICATION FOR PAYMENT AIADOCUMENTG702 PAGE ONE OF PAGES
TO 0 PROJECT: CARMEL CITY APPLICATION NO: I Distribution to:
SIGNATURE CONSTRUCTION SERVICES, LLC. CENTER PHASE 1 PERIOD TO: March 31, 2009 OWNER
ONE PEDCOR SQUARE, 720 THIRD AVE, SW PROJECT NOS: ARCHITECT
CARMEL, IN 46032 LCI JOB# L542 CONTRACTOR
FROM CONTRACTOR: CHECK REMITTANCE ADDRESS. CONTRACT DATE: 8
LITHKO CONTRACTING, INC LITHKO CONTRACTING, INC.
P.O. BOX 270 P.O. BOX 270
MONROE, OHIO 45050 MONROE, OHIO 45050
CONTRACT FOR: Place/Finish Concrete VIA ARCHITECT:
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge,
Application is made for payment as shown below, in connection with the Contract. information and belief the Work covered by this Application for Payment has been
Continuation Sheet, AIA Document G703, is attached. completed in accordance with the Contract Documents, that all amounts have been paid by
the Contractor for Work for which previous Certificates for Payment were issued and
payments received from the Owner, and that current payment shown herein is now due.
1. ORIGINAL CONTRACT SUM 436,000.00
2. Net change by Change Orders 0.00 CONTRACTOR: LITHKO CONTRACTING, INC.
3. CONTRACT SUM TO DATE (Line 1 f 2) 436,000.00
4. TOTAL COMPLETED STORED TO 137,943.75
DATE (Column G on G703) By: Date: March 19, 2009
5. RETAINAGE: ANDR A GA M, BILLING COORDINATOR
a. 10% of Completed Work 13,794.38 State of: 'Cr OHIO County of: WARREN
(Column D E on G703) Subscribed and sw, r' ele�tiiS� 19 day of March, 2 9
b. of Stored Material LE$LI N9V WHEEL
(Column F on G703) Notary Public:
Total Retainage (Lines 5a 5b or My Co ion x 'r
;.byf y t
Total in Column I of G703) 13,794.38 ARCHITEGTPS Cra TE� TE ,EQ.R 7 A MENT
6. TOTAL EARNED LESS RETAINAGE 124,149.38 In accordance withgthentzact'Dacizrnents based on on site observations and the data
(Line 4 Less Line 5 Total) comprising the applie tt rchitect 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) 0.00 /the quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE 124,149.38 is entitled to payment of the AMOUNT CERTIFIED.
9. L RETAINAGE
BALANCE (Line 3 less Line 6 INCLUDING RE GE 311,850.63
I C:) ,/AMOUNT CERTIFIED
i
'nn
CHANGE ORDER SUMMARY j ADDIT -ONS DEDUCTIONS (Attach explana n f amount certified differs from the amount applied. Initial all figures on this
Total changes approved I Application d o the Co uation Sheet that are changed to conform with the amount certifie
in previous months by Owner $0.00 $0.00 ARCHIT T:
Total approved this Month $0.00 $0.00 By: Da 3f
TOTALS $0.00 1 $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 1
CONTINUATION SHEET AIA LVCUA Nl G703 PAGE OF PAGES
AIA Document G702, APPLICATION AND CERTIFICATION FOR PAYMENT, containing APPLICATION NO: 1
Contractor's signed certification is attached. APPLICATION DATE: 3/19/2009
In tabulations bClow, amounts are stated to the nearest dollar. PERIOD TO: 3/31/2009
Use Column 1 on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO:
CARMEL CITY CENTER PHASE i Lthk®
L5429 CONTRACTING, INC.
A B C D E F G f1
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 0.00 4,800.00 0.00 4,800.00 100% 0.00 $480.00
2 MOBILIZATION 5,000.00 0.00 4,000.00 0.00 4,000.00 80% 1,000.00 $400.00
3 GENERAL CONDITIONS LAYOUT 5,000.00 0.00 3,000.00 0.00 3,000.00 60% 2,000.00 $300.00
4 FIRESTOPPING 12,000.00 0.00 9,600.00 0.00 9,600.00 80% 2,400.00 $960.00
5 LIGHT POLE BOLLARD PEDESTALS 20,000.00 0.00 5,000.00 0.00 5,000.00 25% 15,000.00 $500.00
6 MOTOR COURT REBAR INSTALLATION 11,375.00 0.00 2,843.75 0.00 2,843.75 25% 8,531.25 $284.38
7 MOTOR COURT REBAR MATERIALS 38,500.00 0.00 38,500.00 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 0.00 0.00 0.00 0% 6,500.00 $0.00
10 VETERANS WAY REBAR MATERIALS 21,750.00 0.00 21,750.00 0.00 21,750.00 100% 0.00 $2,175.00
VETERANS WAY PREP, PLACE FINISH 49,600.00 0.00 0.00 0.00 0.00 0% 49,600.00 $0.00
HANOVER SQ REBAR INSTALLATION 6,500.00 0.00 0.00 0.00 0.00 0% 6,500.00 $0.00
HANOVER SQ REBAR MATERIALS 21,750.00 0.00 21,750.00 0.00 21,750.00 100% 0.00 $2,175.00
HANOVER SQ PREP, PLACE, FINISH 49,600.00 0.00 0.00 0.00 0.00 0% 49,600.00 $0.00
COURT PLAZA REBAR INSTALLATION 6,500.00 0.00 0.00 0.00 0.00 0% 6,500.00 $0.00
COURT PLAZA REBAR MATERIALS 21,750.00 0.00 21,750.00 0.00 21,750.00 100% 0.00 $2,175.00
COURT PLAZA PREP, PLACE FINISHI 49,600.00 0.00 0.00 0.00 0.00" 0% 49,600.00 $0.00
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 0.00 4,950.00 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 0.00 0% 0.00 $0.00
GRAND TOTALS 436.000.00 1 0.00 137,943.75 0.00 137,943.75 32% 298,056.25 $13,794.38
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 i P IMP92 -20 -1 Effective- 1/31/01
SUBCONTRACTOR'S SWORN STATEMENT OF
INDEBTNESS WAIVER OF LIEN
STATE OF Indiana
J COUNTY OF Hamilton
f
V U Being duly sworn upon his /her oath disposes and
says that: ACE
1. He /she i 1�'1�1NA(E (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 G01vCRF7E 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.
Supplier List (Add list if necessary 1 1. Amount Owed 3
G- 5 -45 00
IN► u� r. MAecW 5rw 1 Xw of 509 =r C0 W
MAU.«0
#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 Z_CSA ao Tr k 12
(Authorized Representati of Subcontractor)
County of IMK4()0
State o f INt)jAN A
Subscribed and sworn to before me, a Notary Public in and for said County and State,
This aolu Day of M 20
(N tary Public)
of
(Printed Name) y
My Commission Expires:
NOTARY SEAL MUST APPEAR ON THIS FORM. (Revised 10/2000 Signat►�
#itir" Ay
6
Lithko Contracting, Inc.
{513 }539 -4144
Remittance Address t.
P.O. BOX 270 r
MONROE, OHIO 45050 C O N T R A C T I N G INC.
149837
TO: SIGNATURE CONSTRUCTION SERVICES, LLC.
ONE PEDCOR SQUARE, 720 THIRD AVE, SW Invoice No.
CARMEL, IN 46032 24760 RI
Invoice Date
3/19/09
Job name: Lithko Job No. Customer Job No. P.O. No.
CARMEL CITY CENTER PHASE 1 L54
Description Amount
DRAW# 1 GROSS 137,943.75
RET 13,794.38
124,149.38
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 1.24,149.38
PAViNIENITBIC
Cite of Carmel
,S'Ilcces,'fiil Bidder must use thLsfiorm or other coniainh q the some 776tt,-riol condifion.v cmd
l?ro Qis aT in advance by 014"'VE'll".
L)cm of Bond n not ")c prior to dme of C Ar' COA is ti It 1). (1
bond
Surety cony)(my exectaing this hondshalt' qpj,)wr (n, "I'le mos;
-,07;1/70nh?.Y
A.Ccenic-lbie or, Federol Bonds. its spec: ',il i �0. os
I fied in the U-5. D Delvilment C
0177CIMICC 077d be (nwhorized to transcict bmsiness in the .Sicmc qflndianci.
KNOW AL;L N BY IT PRIESEENTS: dla*
"CONTIFRACTOR":
Lil Ilk C Cm C r a C t I. r) ITic. 7706 Moller Road I n d i
I
Hartlord Insurance Colllpatlli
[AcIcircss] IIII-L-f Plaza
llartA'ord, (j 06115
a Corporation c1larter-cl and exist undor tht laws of the Siate o
k
Conriect i.cut fln State e
al)d a,lTthOrl:Ztd CO C-10 bLISHICSS I
ofindiama,
are hl-)d and firmly bound unto the Ciuv of Camiel, Indiana hereinafter ca.11ce, MAUNTER, in the
l7tmr Thir'L.Y-S.:;,x Th'ousand
penal SLID of Dollars, (S_
lay. momy o. the U'Tmed States. for the paymorit of v0iich simi Nvell and truly to be macle, plus
into rest at the maxill ra e from Of anv f c2s and C ourl C'Osls
incurred, by 0I)IIgee to c,.nR)rc-- this. instlum-Int. c bind ourselves, successors, and assigns,
10111fly and fill I)v the' presents.
WTIEREAS. tho eniered into a certain Aarl-emen! %vil the ONVNIER dated
as of the 4th dav o-F Fe 1) r i-to r y 0 9 bit ,vhich ("ONf'TRACTOR, has
a
gre.ed to perform and furnish certain Work for t?Ir i n furthelranct of construction of public
ll doscribed ayencralk as (Fill i!i Pro Na and
f 5" C:.rlllcs' City Ccntcr, I'llinsc 1 1 SI—CIPEll TOP! IN'G' is T
The L—nexal scope of lVork consists of topilill" slab over CT fing
ic
L-in" €P Tit n!-!�Ctlst fi—mingy. poles -ud ho
and assuciatc,1
vvhich
ll: by re T"", rcn cc-:
MB-1
VCW THERIEFORE, to conGdons of As o0gatimi ai ",I ,I; 'Unw. if ih CO! TOR shal
proni!pfly make pa yin tnts of all anlowus dm to at Claiman then 1 Clibligalion s"hal'. b- vo
OUT"We to rortiaiii in full force and eff ct. "Claimwl' W nwan '.in-y Subcolit ji-,mok!
supplier or other person, firnn, or co!j)oration Wishing mucrials or equipmun for or
ptrforliliII& labor of services in 1 prosecution of flie Nkork provi'&�d ibr In .�uclli Agreonien
Oluding Wcants, oil, gasoiine, coal and on mac'I'Lino—y.. and! to) S, VVIICLIO!�'
consumed or used in connection xith th 001"StILICliMI OrSUc.h voriw.. and all insura
on said work, and for all labor,. performed in such worlk.
PRO FURTIT ER thm the said Sue,, Rw A ut r2ceived, hereby Quiates and agaves:
1, that no dolct or inegulaTity in the conli met or in the proceedirigs preiiniinary to tli'3
of the Agreeme.-ritwili operate to release: or discharg Surt'.
2. ThIFIt 110 ChW1� 01 t.K of time, altercilion oi aoditioll to tht t"'rnls of tint
Agre-rnent, Contract Document or to any W`ork to bc furnished thoreunder, an6 no delay
by be O\VNER in enforcement of the Agrecnicmt or this bond shall in any way aff:ct its
obhgadun on As bond, and it does hereby Nvaive nodoe of any such chang, wepsion of
time, alteration or addition to the Ams of the Aglow Colfract Documents cn to the
3. that no final settlement between the OW'NEER and 1.11z" C!O!,'jJ' RAC "T'OR. shall al-'ridge Pny
hov of Me. OWER hereunder as to any claim Mai. may ren unsatisfi ed, alld
4. that this Pa. Bond and Surety shall no!. be role }se df until one (1) ycar af the
OWNER'sfinal settlement vviih the CUNTRACTOR.
IN 'XITNES'S 'Vv'-HER.EO-F. t'lliS inSLrUnICII iS eXturted in one Cii.-Lurniber') countei-ParLs. ,acjh
one of which shall be deemed an original, Wis the jak, dad- of Feb)-
CONTRACT [na icl PICHIC-)Uonrracting, Inc.
DiHmfd name]
,,,--ATTEST
-4="�jn '01= S:neWq
A 17 I
1 �n a'�u F'--
if 11-fart:i Insurance Com ;v
I signalu'rej
Sus;)ii A. Yeazell, Wells Fayjjq Insurance S<�-rvic(- of Ohio, LLC
(p6wed namej [address)
1 I V i n e S L.r e e t- S u i t. e I C c i n. I a L i 0 f 1 i1 5 2ll2
2
Direct InquirieslClaims »o:
THE HARTFORD
POWE OF p� BOXz11003.amAS��A���
*ARrpoao.cOwmsoT�uTou��:
rafl:oo8'zss'o4800,ra,:us0'7sr'an33
nwoW ALL PERSONS oY THESE PRESENTS THAT! Agency Code: 33-700077 m33707200
Hartford Fire Insurance Company, ^uonomo":uu/rur:zniz,uunu�"r txr laws vri|cyu,�o�cvan�xcw
Hartford Casualty Insurance Company, ac"rpo*muonu:/xnrl-Imoz2C:nac, o' ,h S'.'o'-^�/,awn;
Hartford Accident and Indemnity Company, xcvrpvri,iov duly organized unvc,/hcuv,vfu`.so,cvrc�roc�icu,
Underwriters Insurance Company, a ou|xolLvoizcuoouco1_-/x°'s Stan- orcon"cc,i,u�
City Fire Insurance Company, o cor duly um^nizt�uunocrm�u"sormcsmcv[/nu/x,x
xartfum msu ran coCompunyo,minnis, xcomo,"itmn6u//o,mo/ Zed Lind crm:/ii "vs erm,m,,c Of* m/coiz
Hartford insurance Company of the Midwest, r, corporilir"T" duly orgv.niz"; unu_-.- th-- la'x, of!ll-_ Stilc o' It"jialla
Hartford insurance Company nf the Southeast, xc^nmmououc/rorca."z^uu,ucrm:lo°,n/0x°s.�`cvr�|vn�,
having their home office in Hartford, Connecticu, (hereinafter collectively reierred to as tne "Clorripanies" do he—eby make, constitute and
up to the amount of unlimited:
Susan A. Yeazek Dan E:. Ries of Cincinnati. OL�*
Deb Marklamt Kimberly DRichanj�Allicheo!D.Ward, Dayton OH
their /,vaanu /avafuiA'xnrrtev(sr/n'raci. �3ux inmei,se is .`ymed ubove, to sign its name r"su��«es)omy as. de/*enteua�*s or and m op,c�a, sea" and acknow any arid all bong,, undsnakinos contracts and other ^,meninstruments m me
nature thereof, on »w`mrofthe Companies in their business of guaranteeing the nu;Uhvrpersons, guaranteeing the pexo,mancomcontracts an:
:x":uhnao,nunmmcaing owoux ung undertakings required or permitted m any actions o,prnceemngsaoowoc by law.
m Witness mmenao;, and ao authorized uva Resolution o, the aoaro.cfo/ectnsv/ the cnrripaniesnn January zz.2OC4the Cvmnox/en
have uaysed/oesepresents to bs signed uy its Assistant Vice President and its corporate seals mbm hereto am=g.Cu|yrxevmmoyxs/aa|n�an�
Sectary. Further,
aric vAl be bound by any mechanically applied sionatures applied to this Power of Attorney.
1007 r
Scott Sauowsky, AssistamSecrelay fV_ Posspuxcr, ASuSt3xtmce Pesmmx
STATE OF CONNECTICUT
Hartford [OUMTY0F*xRTF0RD
On this 3,u day crMarch, 2008. before me personnnroarno M. Roos Pane,, to me xoovin, who uoipg by me duly smn'n. did uepvys a,x
say: that he resides in the County oxHartford, State of cunneonc�� that he is the Assistant m:v President o{the oo=pen�co, txeon9miauu,s
urnmibou in and which executed the above instmrnom; m= he knows the =v|n o( me said ou,pm/auons; that the ooalt. affixed tcl the said
inxtrvm:m are such nnrpmcatosoa|o� that m=ywcre ,o affixed bv authority v/the Boards rvDirector vfvaiC noporauvrs and that lie nioneu his
name moremby like authority,
Scott �,=t;l"
x*=
csmmcms w., Commission s,p/,"�o".":",z,a��
the undersigned, Assistant Vice p,ssidomo/ the Companies oO HEREBY CERTIFY malma above arid foregoing /`a true and co,^aCt
copy the Power or Attorney executed u said Companies, mmu^/ssm|infuomom:n;ctiwaaso/ Fcbruory 5, 2OO9
S/onew and sealed at the City oiMamnnu.
Gary'* s�umper, Aowntanvic*p=s�dsn
Bonci No. 3IBCS
117S 1171 -C i i0 I 7S.'
Succes,�ful J vse 1" f�)rin or o thil�i')'O con,717folir nvn`
d il- cla"vance 7l' n7 as c"'i'213rove
Daic ()/'Bo)-, inust not be ol to dMC 0 C j',r CO3V"'RICTOR f a Gil.'' k-, i.. A
el C0777IM17' h(M ShO' "IM Q� "l H
VOI� Of' !17C
Ac,cevluble 077 Federcil Bonds, ci, specifieW in ih.,,, 7 71 a
7 Dcpanonc (I VId P OS
lume1 ded. and be awhormed to (•ansacl bluinc.s in r/n Sicue Ofll?dicma.
KNONV' ALL, ME NI BY THESE T)r'ES ti-111T
—i- L h k C 0 .1 L ra c i 11 g I Lic 77 0! Mo 1. 1. e r Ro ad I n d i a i i:-) pol s IN 16 2 6 8
and
Ha r( Ford PLre, Insurance Conip'-my
I d I It a r t F -)rd p 1.
Hart. ford 016 1 i5
a C j l afte r ed J,jjd under ill-- ?a %s of the LSTLOtc o.
ConrocViclit: and autfiorizt-d to (10 [)LU lI1 Sti 'D The SIM.I.-, Oflndiama.
Ca
aft held al-ld f I
IF1111V b01- 7.111TO 111C Ci 01 -1 hidian,3 11creinafter callcd UVVNEIT- :11 -.hc
F
11, of ed 11,irC,-Six Thni,isarld
I'l 0 ars, (y) in
penal su ns _�bdr(&,18[ D.!h (S
k-Avful money of t11e United Stags. for ti -c Payment of which sum well andl iruly to be inadc,
toLyc.mClr with mit"resi, an, the maxiII.ILLTI i 1- raic fron-, date of demand and any auornov f "s L111d
COLII-I COSSIS incurred hy ObIlace to enforce this irisuIUM-1111 VVC Mild ourscl-ves. Successors, and
assigns. ioi.ntilt and se-Ncrally, firmly by these, prCscilt.s.
the CONTRACTOR has cm-Ir"d into al. certain Agrecinem with the ON -V7", R, dated
dud of
L 4ch FebrUa ry 0" by wtich CONTTIZACTOR 1-1-as
m �or or 'n furtlie-rancC 0" C-1011SULICt,0111 Of
to pci and fumish c�-rlalin Work I C
improv;m1ems described as 0111 in Proj Name mid Dcscripuion Below):
PARCAE[, 5, Carmel Ci"Iv C."cri-r- I-Ij—qo I �'r r)-P1v*?j
.1 I I.- SL R
tr) Ili F,( a
The genera v scope of 'I) consis' i 1,
ant, I arking im prccasf FramirtL�. I roictef f Huhi r)nics, and
ALi --m. und DOCUIllems" as to fllerC nn- are
bv
T -1
a 3 ""T C 01' l] 1.1
THERE-11FOR-E- the con ch Thm i 'u"t
1 1. till 1 V WIC! f,1JT1 I I V
per,") ni his dud:s. at' t undertakIT)LIS, COVC11TILMII.S. 1.crnas fuld
t and! am z��JZTIS'*101is
11 Oi"Uil
C0110itions Cif. said Aur��emem wllctb�_r dunkil a] th..
her C){ 1i'1111c1i rnav be aranted 13v ihe MVNE \vim or wllhout -41CALice [o flic Suttv an` dur:n_()
1
'.My J)C, od of cuaraim r or vvnn P,-O\,l led thcrc-in or dE'r. and
C0NTTJ\', c_)R' sh?l.l satis.'V all ciaims i Q^i21 Fllilt mcun undo sucil C() straw' and, shall
ful]v incj;mm:fv anci sal na fln4 OWNEk. From� all casts _.nd damaies xvi ;r he suf F
bv rtT.sori of Jfaflur� to do so, and shali .irnbursc -und ;re the 0\ E all o j fl 0
and .xtx_msc
Which th�_ OVVNER inav incur in i-naikina good any (lefault_ flien obii(Eation shall bzt void:
oihenv;se to remain in Full fore' am". -Efcci.
PROVED'E'D. 1h j'.'UR'T'' Said ureiv. for 21 :tom Y��cedv- hereb stipulat,-s and
1 r_K,.. thal uu S
linat 1110 cieft;cl or jn mihmil) in the Contraci or in the proctedlings pr to M_ 111
lenif of the contrac will o cr a i e io cas ol dischat L
I fl no chailLIC. omjssion, exu"nsion 01 unic. ah or additJorl to 4 ie t:' ms of flint-
Agrecineut.. Corrtraci Documents or to any Work to 17c ;Fulnuished therewider, and no delay
by the Q`1' ti 'n enforcemcn;. of mj ,r,- 11 t C) I I
tFrle r nus bond sha,1 in any ,vay afp' ct iis
0 blintion on fliis bond. and it dioes hereby waive no6cu of any suicln z'xttnSion of
tivic, aluen or addition 'Lo the tenns cif the Aurecinent., Conn Docnjmmir or m the
ntlmorn bonvn 1_ R i c C 0
I at Tic final SL ce rhe MN NE and ii I sha"! a, 1 C
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nsti'llmeT.3t is ""'ach
jN WIPNESS W 1 ER LEGF, this it 11c1U*VCJ ifl (Me (11u.rnb�
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SU),ET
hart Eand 11 "'nsurance company
-fact
Susan A. Yeazell wc i. 1, s i r o
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PF13-2)
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.
LI
Payee
gr7 //7 Purchase Order No.
�o �oX 27U Terms
/Y� rG Off L/s O s a
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
3�3i o9 Gl/�,
6 lY9 .32
Total 1 y,/y9
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.
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
�1 610�7�✓�c71 �-5 IN SUM OF
Po
141-- c"./�o� Dl �sosa
ON ACCOUNT OF APPROPRIATION FOR
T1
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
9a2 IYY6o8vS 12y &4.3 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
Signature L
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund