HomeMy WebLinkAbout168693 02/04/2009 CITY OF CARMEL, INDIANA VENDOR 356934 Page 1 of 1
ONE CIVIC SQUARE SIGNATURE CONSTRUCTION LLC CHECK AMOUNT: $456,310.05
CARMEL, INDIANA 46032 720 3RD AVE SW
CARMEL W 46032 CHECK NUMBER: 168693
CHECK DATE: 21412009
DEPARTMENT ACCOUNT PO N INV OICE NU MBER AM OUNT DESCRIPT
902 4460867 1 26,070 INDIANA DESIGN CENTER
902 4460805 14 430,239.50 RETAIL SITE #5
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City of Carmel
Parcel 67 Streetscape Indiana Design Center P12
City Project Number 26236 Robert Indiana Street Work
Budget Review and Distribution Request 2
Period Ending December 22, 2008
Checks to be Made Payable to:
Hagerman Construction Corporation 94,787.37
J Signature Construction, LLC 14,604.45
Total 109,391.82
City of Carmel
Parcel 67 Streetscape Indiana Design Center P12
City Project Number 26236 Robert Indiana Street Work
Budget Review and Distribution Request 2
Period Ending December 22, 2008
PROJECT BUDGET REVIEW SUMMARY
TOTAL WORK THIS PERIOD Current BALANCE Total
Scheduled COMPLETED RETAINAGE Payment PREVIOUS TOTAL COMPLETED TO Retainage
DESCRIPTION Value THIS PERIOD WITHHELD Due APPLICATIONS TO DATE FINISH Held
General Conditions /Requirements 46,150.00 16,152.50 1,615.25 14,537.25 6,922.50 23,075.00 50% 23,075.00 2,307.50
Existing Conditions /SelectiveDemo 8,770.00 0.00 0.00 0.00 8,770.00 8,770.00 100% 0.00 877.00
Concrete 24,430.00 9,772.00 977.20 8,794.80 0.00 9,772.00 40% 14,658.00 977.20
Meltal 2,190.00 306.60 30.66 275.94 1,007.40 1,314.00 60% 876.00 131.40
Specialties (signage) 5,570.00 0.00 0.00 0.00 0.00 0.00 0% 5,570.00 0.00
Electrical 41,640.00 15,823.20 1,582.32 14,240.88 832.80 16,656.00 40% 24,984.00 1,665.60
Earthwork 41,500.00 18,675.00 1,867.50 16 807.50 6,225.00 24,900.00 60% 16,600.00 2,490.00
Exterior Imporvements 70,650.00 0.00 0.00 0.00 10,597.50 10,597.50 15% 60,052.50 1,059.75
Utilities 63,700.00 44,590.00 4,459.00 40 ,131.00 6,370.00 50,960.00 80% 12,740.00 5,096.00
Signature's General Conditions 15,230.00 7,302.23 0.00 7,302.23 0.00 7,302.23 48% 7,927.78 0.00
Signature's Profit Overhead 15 230.00 7,302.23 0.00 7 0.00 7 48% 7 0.00
Total 335,060.00 119,923.75 10,531.93 109,391.82 40,725.20 t 160,648.95 48% 174,411.05 14,604.45
APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE ONE OF l PAGES
TO OWNER: Carmel Redevelopment Commission PROJECT: Parcel 67 APPLICATION NO: Draw Number I Distribution to:
One Civic Square City Project 26236 Signature costs =OWNER
Carmel, Indiana 46032 Robert Indiana Street Work =ARCHITECT
PERIOD TO: 12/22/2008 CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT:
Signature Construction LLC
720 3rd Avenue S.W. PROJECT NOS:
Carmel, Indiana 46032
CONTRACT FOR: CONTRACT DATE: October, 2008
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 30,460.00
2. Net change by Change Orders 0.00 CONTRACTOR:
3. CONTRACT SUM TO DATE (Line 1 f 2) 30,460.00
4. TOTAL COMPLETED STORED TO 14,604.45 J
By- Date: /y zz
5. RETAINAGE: Tom K ntz President
a. 0 of Completed Work ubscribed d worn to before me this 22 day of December, 2008
(Column D E on G703)
K of Stored Material
(Column F on G703) KATHLEEN BARBAGLIA
Total Retainage (Lines 5a 5b or Notary Public -S
Total in Column I of G703) 0.00 ARCHITECT'S CERTIFICATE FOR EW My Commission Expires Oct 13,
6. TOTAL EARNED LESS RETAINAGE 14,604.45 in accordance with the Contract Documents, based on on -site observations and le data
(Line 4 Less Line 5 Total) comprising the application, the Architect certifies to the Owner that to the best e
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 14,604.45 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE 15,855.55
(Line 3 less Line 6) AMOUNT CERTIFIED [Qr�
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach e lion if aunt certified differsfrom the amount applied Initial all figures on this
Total changes approved Applic lion nd o e ontinualion Sheet that are changed to conform with the amount certified.)
in previous months by Owner AR IT T:
Total approved this Month By: Date: [Z D
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 @1992 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.
City of Carmel
Parcel 67 Streetscape Indiana Design Center P12
City Project Number 26236 Rangeline Streetscapes
Budget Review and Distribution Request 2
Period Ending December 22, 2008
PROJECT BUDGET REVIEW SUMMARY
TOTAL WORK RETAINAGE Current BALANCE Total
Scheduled COMPLETED WITHHELD Payment PREVIOUS TOTAL COMPLETED TO Retainage
DESCRIPTION Value THIS PERIOD THIS PERIOD Due APPLICATIONS TO DATE FINISH Held
General Conditions /Requirements 56,800.00 19,880.00 1 988.00 17,892.00 8,520.00 28 400.00 50% 28,400.00 2,840.00
Existing Conditions /Selective Demo 13,150.00 0.00 0.00 0.00 13,150.00 13 ,150.00 100% 0.00 1,315.00
Concrete 36,700.00 9,175.00 917.50 8,257.50 0.00 9,175.00 25% 27,525.00 917.50
Meltal 6,580.00 0.00 0.00 0.00 3,026.80 3,026.60 46% 3,553.20 302.68
Specialties (signage) 8,350.00 0.00 0.00 0.00 0.00 0.00 0% 8,350.00 0.00
Electrical 57,950.00 1,738.50 173.85 1,564.65 1,159.00 2,897.50 5% 55,052.50 289.75
Earthwork 22 3,363.00 336.30 3,026.70 3,363.00 6,726.00 30% 15,694.00 672.60
Exterior Imporvements 46,980.00 2,349.00 234.90 2,114.10 7,047.00 9 396.00 20% 37,584.00 939.60
Utilities 21,220.00 14,854.00 1,485.40 13,368.60 2,122.00 16,976.00 80% 4,244.00 1,697.60
Change Order #1 23,672.00 18,937.60 1,893.76 17,043.84 0.00 18,937.60 80% 4,734.40 1,893.76
Signature's General Conditions 14,691.10 5,434.25 0.00 5,434.25 0.00 5,434.25 37% 9,256.86 0.00
Si nature's Profit Overhead 1 14,691.10 5,434.25 0.00 1 5 0.00 1 5 37% 9,256.85 1 0.00
Total 323,204.20 81,165.60 7,029.71 74,135.89 38,387.80 119,553.40 37% 203,650.81 10,868.49
APPLICATION AND CERTIFICATION FOR PAYMENT 4L4 DOCU MENTG702 PAGE ONE OF 1 PAGES
TO OWNER: Carmel Redevelopment Commission PROJECT: Parcel 67 APPLICATION NO: Draw Number I Distribution to:
One Civic Square City Project 26236 Signature costs =OWNER
Carmel, Indiana 46032 Rangeline StreetScapes ARCHITECT
PERIOD TO: 12/22/2008 OCONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT:
Signature Construction LLC I
720 3rd Avenue S.W. PROJECT NOS:
Carmel, Indiana 46032
CONTRACT FOR: CONTRACT DATE: October, 2008
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 29,382.20
2. Net change by Change Orders 0.00 CONTRACTOR:
3. CONTRACT SUM TO DATE (Line 1 2) 29,382.20
4. TOTAL COMPLETED STORED TO 10,868.50 J
By' Date: /.z�LZ z�
5" RETAINAGE: om KoonU President
a. 0 of Completed Work Sub cri d and wom to before me this 22nd day of
(Column D E on G703) l Qe N SARBAGLIA
b. of Stored Material C s Public seal
(Column F on G703)
Total Retain age (Lines 5a+ 5b or J Of ItldiHna
Total in Column I of G703) 0.00 ARCHITECT'S CERTIFICATE FOR P xP fe ct 13. 2016
6. TOTAL EARNED LESS RETAINAGE 10,868.50 In accordance with the Contract Documents, based on on -site obse
(Line 4 Less Line 5 Total) compr ising 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) 0.00 the quality of the Work is in accordance with the Contract Documents, and the Contractor
8, CURRENT PAYMENT DUE 10,868.50 is entitled to payment of the AMOUNT CERTIFIED.
9, BALANCE TO FINISH, INCLUDING RETAINAGE 18,513.71
(Line 3 less Line 6) AMOUNT CERTIFIED S i O r .J50
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attareanatio if amount certified differs from the amount applied. Initial all figures on this
Total changes approved Appland the Cant a "on Sheet tare changed to conform lvith the amount certified.) in revious months by Owner ARC T:
Total approved this Month By: Date:
TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
Contractor named herem. 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 ®1992 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.
City of Carmel
Parcel 67 Streetscape Indiana Design Center P12
City Project Number 26236 Rangeline Streetscapes
Budget Review and Distribution Request 2
Period Ending December 22, 2008
PROJECT BUDGET REVIEW SUMMARY
TOTAL WORK RETAINAGE Current BALANCE Total
Scheduled COMPLETED WITHHELD Payment PREVIOUS TOTAL COMPLETED TO xetainage
DESCRIPTION Value THIS PERIOD THIS PERIOD Due APPLICATIONS TO DATE FINISH Held
General Conditions /Requirements 56,800.00 19,880.00 1,988.00 17,892.00 8,520.00 28 400.00 50% 28,400.00 2,840.00
Existing Conditions /Selective Demo 13,150.00 0.00 0.00 0.00 13 ,150.00 13 ,150.00 100% 0.00 1,315.00
Concrete 36,700.00 9,175.00 917.50 8,257.50 0.00 9,175.00 25% 27,625.00 917.50
Meltal 6,580.00 0.00 0.00 0.00 3,026.80 3,026.80 46% 3,553.20 302.68
Specialties (signage) 8,350.00 0.00 0.00 0.00 0.00 0.00 0% 8,350.00 0.00
Electrical 57,950.00 1,738.50 173.85 1,564.65 1,159.00 2,897.50 5% 55,052.50 289.75
Earthwork 22,420.00 3,363.00 336.30 3,026.70 3,363.00 6,726.00 30% 15,694.00 672.60
Exteriorlmporvements 46,980.00 2,349.00 234.90 2,114.10 7,047.00 9,396.00 20% 37,584.00 939.60
Utilities 21,220.00 14,854.00 1,465.40 13 368.60 2,122.00 16,976.00 80% 4,244.00 1,697.60
Change Order #1 23,672.00 18,937.60 1,893.76 17,043.84 0.00 18,937.60 80% 4,734.40 1,B93.76
Signature's General Conditions 14,691.10 5,434.25 0.00 5,434.25 0.00 5,434.25 37% 9,256.86 0.00
Signature's Profit Overhead 1 14,691.10 5,434.25 0.00 1 5,434.25 0.00 5,434.25 37% 9 0.00
Total 323,204.20 81,165.60 7,029.71 74,135.89 38,387.80 119,553.40 37% 203,650.81 10,868.49
City of Carmel
Parcel 67 Streetscape Indiana Design Center P12
City Project Number 26236 Curb Cosntruction
Budget Review and Distribution Request 2
Period Ending December 22, 2008
Checks to be Made Payable to:
Hagerman Construction Corporation 5 3?.�0.4 t�(1
Signature Construction, LLC 597.60
Total 5,523.75
City of Carmel
Parcel 67 Streetscape Indiana Design Center P12
City Project Number 26236 Curb Cosntruction
Budget Review and Distribution Request 2
Period Ending December 22, 2008
PROJECT BUDGET REVIEW SUMMARY
TOTAL WORK RETAINAGE Current BALANCE Total
Scheduled COMPLETED WITHHELD Payment PREVIOUS TOTAL COMPLETED TO Retainage
DESCRIPTION Value THIS PERIOD THIS PERIOD Due APPLICATIONS TO DATE FINISH Held
Robert Indiana Street Curbs
General Conditions /Requirements 1,675.00 586.25 58.63 527.63 251.25 837.50 50% 837.50 83.75
Concrete 7,480.00 1,496.00 149.60 1,346.40 0.00 1,496.00 20 5,984.00 149.60
Rangeline Road Curbs
General Conditions /Requirements 1,675.00 586.25 58.63 527.63 251.25 837.50 50% 837.50 83.75
Concrete 11,220.00 2,805.00 280.50 2,524.50 0.00 2,805.00 25% 8,415.00 280.50
Signature's General Conditions 1,102.50 298.80 0.00 298.80 0.00 298.60 27% 803.70 29.88
Signature's Profit Overhead 1,102.50 298.80 0.00 298.80 0.00 298.80 27% 803.70 29.88
Total 24,255.00 6,071.10 547.35 5,523.75 502.50 6,573.60 27% 17,681.40 657.36
APPLICATION AND CERTIFICATION FOR PAYMENT AIADOCUMENTG702 PAGE ONE OF I PAG
TO OWNER: Carmel Redevelopment Commission PROJECT: Parcel 67 APPLICATION NO: Draw Number 1 Distribution to:
One Civic Square City Project 26236 Signature costs =OWNER
Carmel, Indiana 46032 Curb Construction =ARCHITECT
PERIOD TO: 12/22/2008 ®CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT:
Signature Construction LLC
720 3rd Avenue S.W. PROJECT NOS:
Carmel, Indiana 46032
CONTRACT FOR: CONTRACT DATE: October, 2008
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies t hat to the best of the Contractors knowled
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 S 2,205.00
2. Net change by Change Orders 0.00 CONTRACTOR:
3. CONTRACT SUM TO DATE (Line I t 2) 2,205.00
4. TOTAL COMPLETED STORED TO 591.60 Date: L ZL O
QSubschb
5. RETAINAGE: oontz President
a. 0 of Completed Work and sw orn to before me this 2nd day of (Column D E on G703)
b. of Stored Material 1 KATHLEEN BARBAGLIA (Column F on G703) Notary Public -Seal Total Retainage (Lines 5a 5b or State of Indiana
Total in Column I of G703) o.00 ARCHITECT'S CERTIFICATE FOR PAM �trtmtsstan xPtres c
6. TOTAL EARNED LESS RETAINAGE 597.60 In accordance with the Contract Documents, based on on -site obse
(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) 0.00 the quality of the Work is in accordance with the Contract Documents, and the Contractor
S. CURRENT PAYMENT DUE S 597.60 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE 1,607.40
(Line 3 less Line 6) AMOUNT FIED j 7��• b O
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Alta explanat on if amount certified differs from the amount applied. Initial all figures on this
Total changes approved Ap ication an o th o ti ation Sheet that are changed to conform with the amount certified.)
in previous months by Owner A CHITEC
Total approved this Month B Date: (�rW
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 wittiout
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 C1992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE_, N.W., WASHINGTON, OC 20006 -5292
Users may obtain validation of this document by requesting a completed AIA Document D401 Certification of Document's Authenticity from the Licensee.
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
S 1 2'V' y 11 vr^e <0ys7r6l<- LG Purchase Order No.
72 0 3�� /�i�c.,S� Terms
C Date Due
Invoice Invoice Description Amount
Date Number /1 (or note attached invoice(s) or bill(s))
67
G r cd �o '7
Total
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.
cc ALLOWED 20
�l k7 t16�Z.
IN SUM OF
3 o S
f
ON COUNT OF APPROPRIATION FOR
2-
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
0 02- b(I Mv0-1, YS bill(s) is (are) true and correct and that the
Q o'Z- 60 L 7 /0 5&9 materials or services itemized thereon for
59 7 which charge is made were ordered and
received except
20
ture
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
•J
APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENTG702 PAGE ONE OF 2 PAGES
TO OWNER Cannel Redevelopment Commissic PROJECT: Parcel 5B APPLICATION NO Draw Number 14 Distribution to:
One Civic Square Phase I Carmel City Center Signature costs =OWNER
Carmel, Indiana 46032 Motor Court =ARCHITECT
PERIOD TO: 12/18/2008 CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design
Signature Construction LLC
720 3rd Avenue S.W. PROJECT NOS: CSO Project 2 10 10
Carmel, Indiana 46032
CONTRACT FOR: CONTRACT DATE 09/07/2007
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best ofthe 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.
I. ORIGINAL CONTRACT SUM 2,841,863 00
2. Net change by Change Orders 135,639.00 CONTRACTOR:
3. CONTRACT SUM TO DATE (Line I± 2) 2,977,502.00
4. TOTAL COMPLETED STORED TO 2,864,936.00 i
Bv:
5. RETAINAGE: om Ko92 President t
a. 0.05 of Completed Work S 143,246.80 Su scribed an worn to before me this I8nd day of December, 2008
(Column D E on G703)
b. of Stored Material S
(Column F on G703)
Total Retainage (Lines 5a 5b or
Total in Column I of G703) S 143,246.80 ARCHITECT'S CERTIFICATE FOR PAYMENT
6. TOTAL EARNED LESS RETAINAGE 2,721,689.20 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 hest 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) S 2,291,449.70 the quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE 430,239.50 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE 255,812,80
(Line 3 less Line 6) AMOUNT CERTIFIED S
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach Plana on if amo cernjred d fferc from the arnouni applied. Initial all figures on this
Total changes approved Apph Lion a onrhe .onh u ei that are changed to conform with the amount terrified.)
in previous months by Owner AR ITEC
Total approved this Month By: Date: rte%
TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
Contractor named herem, 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 OOCUMENT G702 APPLICATION AND CERTIFICATION FOR PAYMENT 1992 EDITION AIA 61992 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.
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G703 CONTINUATION SHEET Page 2 of 2
To: From: Project: Application No.: `14
Carmel Redevelopment Commission Signature Construction LLC Parcel 5B Application Date: 12/18/08
One Civic Square 720 3rd Avenue S.W. Phase I Carmel City Center Period To: 12/18/08
Carmel, Indiana 46032 Carmel, Indiana 46032 Motor Court Engineer's Project No.
A B C D E F G H I
Work Com leted Materials Total
Presently Completed Balance Retainage
item scheduled From Previous Stored and Stored To if
Description of Work Value Application This Period (Not in To Date (G /C) Finish Variable
D or E) (D +E+F) (C -G)
101 General Requirement 132,109.08 117,577.09 9,247.64 0.00 126,824.73 96% 5,284.36 6,341.24
Bonding 113,675.00 113,675.00 0.00 0.00 113,675.00 100% 0.00 5,683.75
Insurance 25,000.00 25,000.00 0.00 0.00 25,000.00 100% 0.00 1,250.00
102 Existing Conditions 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
103 Concrete 2,170,090.00 2,157,460.00 12,630.00 0.00 2,170,090.00 100% 0.00 108,504.50
104 Masonry 50,000.00 0.00 0.00 0.00 0.00 0% 50,000.00 0.00
105 Metals 19,368.00 0.00 0.00 0.00 0.00 0% 19,368.00 0.00
106 Wood, Plastics and Composites 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
107 Thermal and Moisture Protection 68,430.00 30,926.00 19,734.00 0.00 50,660.00 74% 17,770.00 2,533.00
108 Openings 6,100.00 0.00 0.00 0.00 0.00 0% 6,100.00 0.00
109 Finishes 26,360.00 0.00 26,360.00 0.00 26,360.00 100% 0.00 1,318.00
110 Specialties 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
111 Equipment 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
112 Furnishings 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
113 Special Construction 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
114 Conveying Equipment 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
121 Fire Suppression 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
122 Plumbing 31,000.00 0.00 31,000.00 0.00 31,000.00 100% 0.00 1,550.00
123 Heating, Ventilation AC 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
125 integrated Automation 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
126 Electrical 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
127 Communications 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
128 Electronic Safety Security 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
131 Earthwork 89,640.00 0.00 80,000.00 0.00 80,000.00 89% 9,640.00 4,000.00
132 Exterior Improvements 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
133 Utilities 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
134 Transportation 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
140 Process Integration 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
141 Material Processing Handling Equip. 0.00 0.00 0.00 0.00 0.. 00 0% 0.00 0.00
144 Pollution Control Equipment 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Change Orders: 0.00
CCC.P100MC -CRCO2 49,400.00 0.00 49,400.00 0.00 49,400.00 100% 0.00 2,470.00
CCC.P100MC -CRCO3 46,989.00 0.00 46,989.00 0.00 46,989.00 100% 0.00 2,349.45
CCC.P100MC -CRC04 39,250.00 0.00 39,250.00 0.00 39,250.00 100% 0.00 1,962.50
Construction Fee 0,090.91 97,980.91 7,706.36 0.00 105,687.27 96% 4,403.64 6,284.36
02.00 2,542,619.00 322,317.00
r-2, 0.00 2, 864,936.00 96% 112,566.00 143,246.80
P
PARTIAL
Payment to Foilow
AFFIDAVIT AND WAIVER OF LIEN
STATE OF INDIANA
SS:
COUNTY OF HAMILTON
Tom Koontz being duly sworn states that he is the President of SIGNATURE
CONSTRUCTION, LLC having contracted to furnish certain materials and /or labor as
follows: Site Development for a project known as Parcel 5B Phase I Carmel City
Center Motor Court located at CARMEL, IN and owned by Carmel Redevelopment
Commission and does further state:
PARTIAL WAIVER: that the balance due from the owner is the sum of four
hundred thirty thousand two hundred thirty nine
dollars and fifty cents (430,239.50) the payment of which
has been promised as the sole consideration for this
Affidavit and Partial Waiver of Lien which is given to and
for said amount, effective upon receipt of such payment.
THEREFORE, the undersigned waives and releases unto the Owner of said premises any
and all lien or claim whatsoever on the above described property and improvements
thereon on account of labor or material or both, furnished by the undersigned thereto, and
further certifies that no other party has a any claim or right to a lien on account of any
work performed or material furnished to the undersigned for said project, and within the
scope of this affidavit and waiver.
SIGNATURE CONSTRUCTION, L LC
'q/ F
m Koontz
President
ubscribed and sw rn to before me this: �'l [_FU O r �E« I►'IgE. Zr�ug
Notary Pub \Q G
KATKEEN
ty Pam Std
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comma ftft 00 19, MS
l
1
IiM�`�7/� 711f�AJ� IiFB�
eRa 211duq Viejo
swul to Iwo
8t13� ,�e rsd r� eat
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.
1 Payee
S% Ah0 /�ylr' ��y ✓�c�i'u�� L`C Purchase Order No.
72 G 3 r� �y�, 5: Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
I y
Total q30 27 3 9 s o
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.
ta
ALLOWED 20
��yrG/9rvr,� C'6�, S� ✓�icT'oy, L-�
IN SUM OF
�'3a 23g.s6
ON ACCOUNT OF APPROPRIATION FOR
Board Members
Po# or INVOICE NO. ACCT /TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
902 6 d YO S 3 o 239 50 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
20
rll Si nat�lxe
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund