207090 03/13/2012 CITY OF CARMEL, INDIANA VENDOR: 365624 Page 1 of 1
ONE CIVIC SQUARE HIS CONSTRUCTORS INC CHECK AMOUNT: $7,220.97
CARMEL, INDIANA 46032 5150 E 65TH STREET SUITE B
oM ,�o INDIANAPOLIS IN 46220 -4817 CHECK NUMBER: 207090
CHECK DATE: 3113/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
211 R4462300 25806 5 7,220.97 WESTWOOD DRIVE BRIDGE
CONSTRUCTION PROJECT INVOICE
DATE: February 28, 2012
COMPANY NAME: HIS Constructors, LLC
AND ADDRESS 5150 East 65` Street, Suite B
Indianapolis, Indiana 46220
TELEPHONE NO.: (317)- 284 -1195
FAX NO.: (317)- 284 -1185
Q�D k O
PROJECT NAME: Hamilton County Bridge 289 3 J0
Westwood Drive over Mitchner Ditch
PROJECT NO.: 11 -08
INVOICE NO.: 5
TOTAL EARNINGS TO DATE: 139,750.34
MINUS 10% RETAINAGE: 13,975.03
TOTAL EARNED MINUS RETAINAGE: 125,775.31
MINUS PREVIOUS PAYMENTS: 118,554.34
TOTAL AMOUNT DUE: 7,220.97
/o &W a_ k-.
an Greska
Construction Manager
City of Carmel
APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT G702 PAGE 1 OF 3 PAGES
TO: City of Carmel PROJECT: Carmel Bridge 289 APPLICATION NO: 5 Distribution to:
One Civic Square. PERIOD TO: 01/31/12 OWNER
I Carmel, IN 46032 PROJECT NOS: #11 -08 HENGINEER
I
PURCHASE ORDER: CONTRACTOR
OTHER
FROM: HIS Constructors, Inc VIA: INVOICE DATE: w i2/9%2012as
5150 E. 65th Street, Suite B
Indianapolis, IN 46220 CONTRACT DATE: 8/312011
CONTRACT FOR:
SUBCONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractors knowledge, information and belief the Work covered by
this application for Payment has been completed in accordance with the Contract Documents, that all amounts have been
Application Is made for payment, as shown below, in connection with the contract. paid by the Contractor for Work for which previous Certificates were issued and payments received from the Owner, and that
Continuation Sheet, AIA Document G702, is attached. current payment shown herein is now due.
1. ORIGINAL CONTRACT SUM 154,800.00 SUBCONTRACTOR: HIS Constructors, Inc
2. Net change by Change Orders (15,049.66) �f-
g)r f/ Date: 219 12012
3. CONTRACT SUM TO DATE (Line 1 t 2) 139,750.34
State of: Indiana
4. TOTAL COMPLETED TO DATE 139,750.34
(Column J on G703) County of: Marion
5. RETAINAGE:
a. 10 of Completed Work 13,975.03 Subscribed and sworn to before
No this 9t day of February,
b. 0 of Stored Material Nota ry Public:
My Commission is 8/22/2012
Total Retainaoe (Line Sa 5b) 13,975.03 SUBCONTRACTORS CERTIFICATE FOR PAYMENT
6. TOTAL EARNED LESS RETAINAGE 125,775,31 In accordance with the Contract Documents, based on on -site observations and the data comprising this application,
(Line 4 less Line 5 Total) the Architect certifies to the Owner that to the best of the Architect's knowledge, information and belief the Work has
progressed as indicated, the quality of the Work is in accordance with the Contract Documents, and the Contractor is
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT
entitled to payment of the AMOUNT CERTIFIED.
(Line 6 from prior Certificate) 118,554.34
8. CURRENT PAYMENT DUE
7,220.9
9. BALANCE TO FINISH 10. VARIANCE TO CONTRACT AMOUNT CERTIFIED 7,220.97
13,975.03 (15,049.66) (Attach explanation if amount certified differs from the amount applied for. Initial all figures on this Application and
on the Continuation Sheet that are changed to conform to the amount certified.)
CHANGE ORDER BY SUMMARY ADDITIONS DEDUCTIONS OWNER: CITY OF CARMEL
l Total changes approved in
previous months by Owner By: CAL Date:
Total approved this Month 15,049.66
TOTALS 15,049.66 This Certificate is not negotiable. The AMOUNT CERTIFIED Is p yable only to the Contractor named herein. Issuance, payment and
NET CHANGES by Change Order 15,049.66 acceptance of payment are without prelutfice to any rights Of the Owner or Contractor under this Contract.
AIA DOCUMENT 0702 APPUCATION AND CERTIFICATE FOR PAYMENT 1992 EDITION -AIAM 01992 -THE AMERICAN INSTITUTE OF ARCHITECTS. 173s NEW YORK
M AVENUE, N.W., WASHINGTON, D.C. 2000&5292 WARNING: Utrstrkted ptrot000pyYrg taws and will subject the violator to legal proseculm G702-1992
I 'This d-ard has been reproduced sioclrerkolly wM the pemikslon of The American Institute of AreMteds under Ucerne 970003 Primavera Systoms, Ine. Reproduction of this d-n! without project- sped9c kdonraion Is hot Ir mitted. Contact The American beiatte of Archriects to verity the cement version of this doamtem and Icense
ct,rhV
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Application and Certificate For payment- page 2
To Owner: CITY OF CARMEL Application No: 5 Date: 02/09/12 Period To: 01/31/12
From (Contractor): HIS CONSTRUCTORS, INC. Contractor's Job-Number: 110025
Project: CI OF CARMEL BRIDGE 289 A Project No:
Work Completed Work Completed Completed and Stored To Date
Previous Application Thls Period
Item Unit Contract Scheduled
Number Description Price Quantity UM Value Quantity Amount Quantity Amount Quantity Amount Retention Memo
01
001 CONSTRUCTION ENGINEE 2,400.0000 1.00 LS 2,400.00 100.00% 2,400.00 0.00% 0.00 100.00% 2,400.00 100.0 240.00
RING
002 MOBILIZATION AND DEM 7,BD0.0000 1.00 LS 7,800.00 100.00 7,800.00 0.00% 0.00 100.00% 7,800.00 100.0 780.00
OBILIZATION
003 CLEARING RIGHT OF WAY 5,718.2000 1.00 LS 5,716.20 100.00% 5,718.20 0.00% 0.00 100.00% 5,718.20 100.0 571.82
004 TEMPORARY IN-STREAM SILT 1,000.0000 .00 LSU 0.00 .00 0.00 .00 0.00 .00 0.00 0.0 0.00
BASIN
005 EXCAVATION COMMON 55.0000 138.00 CYS 7,590.00 138.00 7,590.00 .00 0.00 138.00 7,590.00 100.0 759.00
006 EXCAVATION WATERWAY 45.0000 .00 CYS o.DD .00 0.00 .00 0.00 .00 0.00 0.0 0.00
007 EXCAVATION FOUNDATI ON 35.0000 52.00 CYS 1,820.00 5200 1,820.00 .00 0.00 52.00 1,820.00 100.0 182.00
UNCLASSIFIED
008 TEMPORARY SILT FENCE 2.7500 .00 LFT 0.00 .00 0.00 .00 0.00 .00 0.00 0.0 0.00
UNDISTRIBUTED
009 AGGREGATE FOR END BE NT 70.0000 25.09 CYS 1,756.30 25.09 1,756.30 .00 0.00 25.09 1,756.30 100.0 175.63
BACKFILL
010 COMPACTED AGGREGATE 53 30.0000 181.71 TON 5,451.30 181.71 5,451.30 .00 0.00 181.71 5,451.30 100.0 545.13
BASE
011 HMA SURFACE TYPE A 119.0000 3210 TON 3,819,90 32.10 3,819.90 .00 0.00 32.10 3,819.90 100.0 381.99
012 HMA INTERMEDIATE TYPE A 106.0000 59.61 TON 6,318.66 59.61 6,318.66 .00 0.00 59.61 6.31B.66 100.0 631.87
013 HMA BASE TYPE A 88.0000 65.96 TON 5,804.48 65.96 5,804.48 .00 0.00 65.96 5,804.48 100.0 580.45
014 BENCHMARK 500.0000 1.00 EAC 500.00 1.00 500.00 .00 0.00 1.00 500.00 100.0. 50.00
015 BURIED TIMBER GUARDRAIL 1,300.0000 4.00 EAC 5,200.00 4.00 5,200.00 ,00 0.00 4.00 5,200.00 100.0 520.00
END SECTION INS
016 TIMBER GUARDRAIL IN STALL 41.0000 96.00 LFT 3,936.00 96.00 3,936.00 .00 0.00 98.00 3,936.00 100.0 393.60
ONLY
017 TIMBER BRIDGE RAIL INSTALL 48.0000 84.00 LFT 4,032.00 84.00 4,032.00 .00 0.00 84.00 4,032.00 100.0 40320
ONLY
018 GEOTEXTILES 25000 72.00 SYS 180.00 72.00 180.00 .00 0.00 72.00 180.00 100.0 18.00
019 RIPRAP CLASS 1 24 DEPTH 35.0000 21.02 TON 735.70 21.02 735.70 .00 0.00 21.02 735.70 100.0 73.57
020 SEED MIXTURE R 47.0000 4250 Las 1,997.50 42.50 1,997.50 .00 0.00 42.50 1,997.50 100.0 199.75
021 FERTILIZER 2,100.0000 .05 TON 105.00 .05 105.00 .00 0.00 .05 105.00 100.0 10.50
022 MULCHED SEEDING T 3.0000 .00 SYS 0.00 .00 0.00 .00 0.00 .00 0.00 0.0 0.00
UNDISTRIBUTED
023 TEMPORARY EROSION CO 4.0000 800.00 SYS 3,200.00 800.00 3,200.00 .00 0.00 800.00 3,200.00 10D.0 320.00
NTROL BLANKET
024 MOBILIZATION AND DEM 265.0000 1.00 EAC 265.00 1.00 265.00 .00 0.00 1.00 265.00 100.0 26.50
OBILIZATION FOR SEED
025 END BENT DRAIN PIPE 6 13.0000 75.00 LFT 975.00 75.00 975.00 .00 0.00 75.DD 975.00 100.0 97.50
DIAMETER
026 SAW CUT JOINT 13.0000 40.00 LFT 520.00 40.00 520.00 .00 0.00 40.00 520.00 100.0 52.00
027 PILING STEEL H PI LES HP 65.0000 312.00 LFT 20,280.00 312.00 20,280.00 .00 0.00 312.00 20,280.00 100.0 2,028.00
12X53
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Application and Certificate For Payment page 3
To Owner: CITY OF CARMEL Application No: 5 Date: 02/09/12 Period To: 01/31/12
From (Contractor): HIS CONSTRUCTORS, INC. Contractor's Job Number: 110025
P CITY OF CA BRIDGE 289 Architect's Project No:
Work Completed Work Completed Completed and Stored To Date
Previous Application Thls Period
Item Unit Contract Scheduled
Number Description Price Quantity UM Value Quantity Amount Quantity Amount
Quantity Amount Retention Memo
028 EPDXY COATED REINFOR 1.2000 4140.00 LBS 4,968.00 4140.00 4,968.00 .00 0.00 4140.00 4,968.00 100.0 496.80
CING STEEL
029 CONCRETE A SUBSTRU 950.0000 21.20 CYS 20,140.00 21.20 20,140.00 .00 0.00 21.20 20,140.00 100.0 2,014.00
CTURE
030 STRUCTURAL MEMBRANE 30.0000 150.00 SYS 4,500.00 150.00 4,500.00 .00 0.00 150.00 4,500.00 100.0 450.00
WATERPROOFING
031 WS 17 X 4'-0 CONCRETE 7.0000 924.00 SFT 6,468.00 924.00 6,468.00 .00 0.00 924.00 6,468.00 100.0 646.80
BOX BEAMS INSTA
032 SURFACE SEAL 1,150.0000 1.00 LS 1,150.00 100.00% 1,150.00 0.00% 0.00 100.00% 1,150.00 100.0 115.00
033 FIELD TILE UNDISTRIBUTED 15.0000 .00 LFT 0.00 .00 0.00 .00 0.00 .00 0.00 0.0 0.00
034 CONSTRUCTION SIGN TYPE 130.0000 B.00 EAC 1,040.00 8.00 1,040.00 .00 0.00 8.00 1,040.00 100.0 104.00
A
035 CONSTRUCTION SIGN TYPE 70.0000 2.00 EAC 140.00 2.00 140.00 .00 0.00 2.00 140.00 100.0 14.00
B
036 STANDARD BARRICADE TYPE 13.0000 48.00 LFT 624.00 46.00 624.00 .00 0.00 48.00 624.00 100.0 6140
IIIA
037 STANDARD BARRICADE TYPE 14.0000 48.00 LFT 672.00 48.00 672.00 .00 0.00 48.00 672.00 100.0 67.20
I IIIB
038 DETOUR ROUTE MARKER 140.0000 7.00 EAC 980.00 7.00 980.00 .00 0.00 7.00 980.00 100.0 98.00
ASSEMBLY
I f 039 ROAD CLOSURE SIGN AS 160.0000 4.00 EAC 640.00 4.00 640.00 .00 0.Co 4.00 640.00 100.0 64.00
SEMBLY
040 EWA2 GPR UTILITY LOC 880.0000 1.00 LS 880.00 0.00% 0.00 100.00% 680.00 100.00% 880.00 100.0 88.00
041 EWA3 END BENT RR 5,676.5800 1.00 LS 5,676.58 0.00% 0.00 100.00% 5,676.58 100.00% 5,676.58 100.0 567.66
042 EWA4 ANCHOR BOLTS 673.5500 1.00 LS 673.55 0.00% 0.00 100.00% 673.55 100.00% 673.55 100.0 67.36
043 EWAS TIMBER RAIL 793.0700 1.00 LS 793.07 0.00% 0.00 100.00% 793.07 100.00% 793.07 100.0 79.29
800 LOAD AND TRANS WOOD RAIL 0.0000 1.00 LS 0.01 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.0 0.00
PIECES
900 OVERHEAD 0.0000 1.00 LS 0.01 0.00% 0.00 0.00% 0.00 0.00% 0.00 0.0 0.00
Total 139,750.26 131,727.04 8,023.20 139,750.24 13,975.02
Application Total 139,750.26 131,727.04 8,023.20 139,750.24 13,975.02
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Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 207 (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.
Ice Mountain Payee
Purchase Order No.
P.U. Box
Terms
Louisville, KY 40285 -6680
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
03/02112 02B Rent and Servie $13.46
ccn
p.
f.
s,
.r
Total Ilk 0.
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
HIS Constructors, I I C IN SUM OF
5150 East 65th Street Suite B
Indianapolis, IN 46220
$7,220.97
ON ACCOUNT OF APPROPRIATION FOR
Department of Engineering
Board Members
Po# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT 1 hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
25806 5 211- R4462300 $7,220.97 which charge is made were ordered and
received except
31i2 �tZ 20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund