HomeMy WebLinkAbout209599 06/05/2012 CITY OF CARMEL, INDIANA VENDOR: 365304 Page 1 of 1
0 ONE CIVIC SQUARE L &T PAINTING
CARMEL, INDIANA 46032 43347 WOODBRIDGE DRIVE CHECK AMOUNT: $85,000.00
CLINTON TOWNS MI 49426 CHECK NUMBER: 209599
CHECK DATE: 61512012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
601 5023990 1 20,000.00 OTHER EXPENSES
601 5023990 2 65,000.00 OTHER EXPENSES
Contra_cto Applic F Payment No. 2.
Application Period: Y I I—iO� fpplication Dale:
'(o (Owncn), O From (Contractor): 1 Via (Engineer)
1 J i i i G l X o» 11 rl
Project: Gontract:
500,000 Jorroe��dgp 5 OD le o,�
Owner's Contract No Contractor's Project hlo. Engineer's Project No.:
y 21- °i-04� -i1
APPLICATION FOR PAYMENT
Change Order Summary PRICE
a le
1
Ahl�roved Change Oideis C'
1. ORIGINAI. ON I PACT 70_.
Z
Number Additions Deductions 2. Net change by Change Orders.., I.
3. CURRENT CONTRAC Im PRICE (Line 1 1 2) fi
4. DOTAL COMPLETED AND STORED TO DATE
(Column F on Progress Estimate)
5. RITAINAGE.
a. x 9 Work Completed 1;
f
i:,. x Stored Material :i
c. Total Retainac line 5a Line 51)
G. AMOUNT ELIGIBLE 10 DATE (Line 4 Line tic)... 9.
TOTAI_S 7. I -TSS PREVIOUS PAYMENTS (Line 6 floor p•iot Application). b
8. AMOUNT DUE THIS APPLICATION
NLT CHANGE BY 9, FIAl_ANCE "10 FINISH, PLUS RETAINAGI-
CHANGE ORDERS COIUmn G on Proc iess Estimate s Line 5 above
CONTRACTOR'S CERTIFICATION DOO
1 he undersigned Conlractor cerlifies that ('1) all previous prog!ess payments received Payment of: r a
from Owner on account of Work clone Under the Contract have been applied on (Line 8 i r other atlacl explanation of other amount)
account to discharge Contractor's legitimate obligralions incurred in connection with
Work covered by prior Applications for Payment, p) Lille of all Work, materials and
equipment incorporated in said Work or otherwise listecl in or covered by this is recommended by
Application for Payment will pass to Owner et time of payment free and clear of all Weer) (Dale)
Hens, security interests and encumbrances (except such as are covered by a Bond
acceptable to Owner indemnifying Owner agafnsl any such Liens, security interest or Payment of:
encumbrances); and (3) all Well< covered by Ihis Application for Payment is in (Line B or other allach explanation of other amount)
accordance with the Contract Doctunents en-i i° defective
is approved by
(Owner) (pate)
Fly: Date Approved by
Funding Agency (if applicable) (Dal f
F No. G620 (20(12 Edition) Page 1 otJ
Prepared by the Engineers' Jo int Co ntract llocu committee and endorsed by the Associated C�encral Contr ofAmeriea send th Consh•octio Specific Institute.
d
1
Contractor A F P aymen t N
-�-Ppllcatlon Period: 01 2— Application Dale
Joel Gontlact:
ownel's contlact 1\10. C.�litractor's Project No.' jEngineem's Piojecl No.:
AppucxTmw FOR PAYMENT
cxuuov Order Summary
on|awxLoowrnxoTpn|os
Not change by Change omois
3. CURRENT CONTRACT pmcs (Lino 1:1: z) ����Ll__----
4. nz7xLuoMpLcTco AND STORED ToDATE
(Column F vo p,vu*ns sonmom) e 0C
s. nsrAmxsc:
a, %x$ Work Completed
x*sumu Material
c Total nmamaue (Lino oo+ Line uo)
G. w/c�
xwmu /o/aLsro oxrs<uon^ Line n4
1 VA[S r. Lsou PREVIOUS PAYMENTS (Line o from pno, Application)
u. xMouwTousTmo APPLICATION
O
wsTcxxwoeaY o. BALANCE 10 FINISH, PLUS nsTx|wxop
CHANGE ORDERS (commoo oil pmo=x, Estimate Line on»",*)
CowTnxoTom`oCsnTmcxr[ON
hom Owner oil account of Work done m)(lei Me Contract have been applied oil -11 8 1 other allach xplarlatiorl of ojjjc,�j �,jr1lo(rilt)
,1 CcOLN't to Contiact l
Work covered by ptior Applicatiorls for Flaymeni, (2) tille of ,)it Work, mateiials and
equipment incorpoiated in said Work ot othemiso listed it) or coveied by this is iecommencled by:
at lime of paymer free and deal of all ligillee e)
Applicatioll for Payment will pass to Owner ID
Liens, sectnily in(erests and encumbiances (except such ale covered by a Bond
accoplable to Owner indemnifying Owner againSt �jljy sticil Ijel)S, SeCUrty intejesl oi Payment of:
ell ell In bi a (ices), and (3) all Woik coveted I)y [lit,- Application for Payment is ill (Line 8 or other at(ach explanatioll of other arnounO
FUrlding Agency (if applicable) (Dato)
oJcucm^ G620 (2002 Edition) "o o)
Prepared by the E'ngiiicers' Joint Colltract Docoolvilts Committee o endorsed
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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
365304
L T PAINTING Purchase Order No.
43347 Woodbridge Drive Terms
Clinton Towns, MI 49426 Due Date 6/4/2012
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
6/4/2012 1 $20,000.00
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
Gil ylj v
Date Officer
VOUCHER 121120 WARRANT ALLOWED
365304 IN SUM OF
L T PAINTING
43347 Woodbridge Drive
Clinton Towns, MI 49426
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
1 01- 6360 -06 $20,000.00
000, 0
Voucher Total
Cost distribution ledger classification if
claim paid under vehicle highway fund