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Home My WebLink About179845 11/24/2009 CITY OF CARMEL, INDIANA VENDOR: 356934 Page 1 of 1 ONE CIVIC SQUARE SIGNATURE CONSTRUCTION LLC CARMEL, INDIANA 46032 720 3RD AVE SW CHECK AMOUNT: $10,657.70 CARMEL IN 46032 CHECK NUMBER: 179845 CHECK DATE: 11/24/2009 i° DEPARTMENT ACCOUNT PO NUMBER I NUMBER AMOUNT DESCRIPTION 902 4460805 1 5,764.08 RETAIL SITE #5 '902 4460894 1 4,893.62 RANGE LINE ROAD -SOUTH P APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE ONE OF 2 PAGES2 y TO OWNER CRC at City of Carmel PROJECT: Parcel 94 Streetscape APPLICATION NO: Invoice u 2 1 Distribution to: Invoice 2 Signature costs =OWNER Carmel Indiana 46032 =ARCHITECT PERIOD TO: 10/26/09 CONTRACTOR FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design Signature Construction Services LLC 720 3rd Avenue S.W. PROJECT NOS: Carmel, Indiana 46032 CONTRACT FOR: CONTRACT DATE: 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. 1. ORIGINAL CONTRACT SUM 12,931.86 2. Net change by Change Orders 0.00 CONTRACTOR: 3. CONTRACT SUM TO DATE (Line I t 2) 12,931.86 4. 'TOTAL COMPLETED STORED TO 11,906.61 r By: C Date: z 5. RETAINAGE: omas oontz, President a. 0 of Completed Work 0 Subs ibed atilsworn to before me this day of October, 200 (Column D E on G703) b. Y. of Stored Material B•.,, LINDA BUCHANAN (Column F on G703) Hancock County :4+o�.nv "total Retainage (Lines 5a 5b or s .z,,` My Commission Expires Total in Column I ofG703) 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT of August 20, 2ott 6. TOTAL EARNED LESS RETAINAGE 11,906.61 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) 7,012.99 the quality of the Work is in accordance with the Contract Documents, and the Contractor 8. CURRENT PAYMENT DUE 4,893.62 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH, INCLUDING RETAINAGE 1,025.25 (Line 3 less Line 6) AMOUNT CERTIFIED 51 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanali 1 amount certified differ. Toni the umoan! uppliecl. Initial all figures on this Total changes approved Application a onl e Continu on S lace! that are changed to conform with the umount cerliJied) in previous months by Owner ARCHITE Total approved this Month By: Date: Q Q I'OTALS 1 $0.00 1 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named nerem. Issuance, payment ana 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. f D CONDITIONAL AFFIDAVIT AND WAIVER OF LIEN STATE OF INDIANA COUNTY OF HAMILTON Thomas E. Koontz being duly sworn states that he is the President of Signature Construction, LLC having contract to furnish certain materials and or labor as follows: Construction Management Services for a project known as Parcel 94 Streetscape, located at Carmel, Indiana and owned by the Carmel Redevelopment Commission and does state: CONDITIONAL WAIVER: that the balance due from the owner is the sum of Four thousand eight hundred ninety -three dollars and sixty-two cents ($4,893.62) the payment of which has has been promised as the sole consideration for this Affidavit and Conditional Waiver of Lien which is given to and for said amount, effective upon receipt of such cash payment. THEREFORE, the undersigned waives and releases unto the Owner of said premises any and all line or claim whatsoever on the above described property and improvements thereon on account of labor or material or both, finished by the undersigned thereto, and further certifies that no other party has any claim or right to a lien on account of any work perform or material furnished to the undersigned for the said project, and within the scope of this affidavit and waiver. SIGNATURE CONSTRUCTION, LLC Th as Koontz, resideXubscribed an d sworn to before me this: 2� goo f Notary Public. LINDA BUCHANAN nor;.::•- Hancock County My Commission Expires August 20, 2011 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 C a%l,}�r'ccf;c1;_-9 �S -5 LL e Purchase Order No. v Terms 2 Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) a Total Z 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. c 11 ALLOWED 20 S /;SN /Vy>o �lic�sJ�r�c "Uh IN SUM OF ?2y y X93.62 ON ACCOUNT OF APPROPRIATION FOR Board Members PO# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or `q9..6 z 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 /r -1z 20 a9 Si ature DhCtar Of pA ons Cost distribution ledger classification if claim paid motor vehicle highway fund APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE ONE OF 2 PAGES2 TO OWNER CRC at City of Cannel PROJECT: Carmel City Pi I I Waterproofing APPLICATION NO Invoice 1 1 Distribution to: One Civic Square Signature costs =OWNER Carmel Indiana 46032 =ARCHITECT PERIOD TO: 10/26/09 CONTRACTOR FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design Signature Construction Services LLC 720 3rd Avenue S.W. PROJECT NOS: Carmel. Indiana 46032 CONTRACT FOR: CONTRACT DATE: 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. I. ORIGINAL CONTRACT SUM 5,764.08 2. Net chanee by Chanee Orders 0.00 CONTRACTOR: 3. CONTRACT SUM TO DATE (Line I t 2) 5,764.08 4. TOTAL COMPLETED K STORED TO 5,764.08 f By: /I Date: /A�a -2A �J 5. RETAINAGE: Thom Koontz, President a. 0 of Completed Work 0 Sub ribed an sworn to before me this day of October. 2009 (Column D E on G703) b. of Stored Material LINDA BUCHANAN d .01A.r Hancock County (Culunum I on 6703) M Commission Expires Total Retainage (Lines 5a 5b or y Total in Column I of G703) 0.00 ARCHITECT'S CERTIFICATE FOR PAYMEN 01 6. TOTAL EARNED LESS RETAINAGE 5,764.08 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) 0.00 the quality of the Work is in accordance with the Contract Documents, and the Contractor 8. CURRENT PAYMENT DUE 5,764.08 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH, INCLUDING RETAINAGE 0.00 (Line 3 less Line 6) AMOUNT CERTIFIED CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanatio a ount certified differsfrom the amount applied. Initial allJigures on this Total changes approved Application a onthe ontin i n Sheet that are changed to conform xvith the atnoiint certified.) M in previous months Owner ARCHITE Total approved this Month By: Date: Q TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named nerem. issuance, payment and acceptance of payment are without NE 1 CI IANGFS by Chanee 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. i 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. Payee 1 _5 /��y C Ste. L& Purchase Order No. 720 3�� S.Gr/ Terms Date Due Invoice Invoice Description Amount Date Number y (or note attached invoice(s) or bill(s)) 7K�j� 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. �C ALLOWED 20 `S�ys�r /v ✓,o �071 �n•vic S LC IN SUM OF 7 2, ON ACCOUNT OF APPROPRIATION FOR �J F 110 Board Members PO# or DEPT. INVOICE NO. ACCT #/TITLE AMOUNT I hereby certify that the attached invoice(s), or fog NyGa�S S7GS!o� 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 11 200y fa Si ature pi le Cost distribution ledger classification if claim paid motor vehicle highway fund