211271 07/31/2012 CITY OF CARMEL, INDIANA VENDOR: T358284 Page 1 of 1
ONE CIVIC SQUARE F.A.WILHELM CONSTRUCTION CO INC CHECK AMOUNT: $236,379.00
`.? CARMEL, INDIANA 46032 PO BOX 516
o� INDIANAPOLIS IN 46206 CHECK NUMBER: 211271
CHECK DATE: 7/31/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
609 5023990 17 236, 379 . 00 OTHER EXPENSES
APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE ONE OF 1 PAGES ` "
TO OWNER:City of Carmel Board of Public Works APPLICATION NO 17 Distribution to:
One Civic Square PROJECT: Carmel WTP#I aX OWNER
Cannel,IN 46032 PERIOD TO 5/31/2012 ARCHITECT
FROM CONTRACTOR: VIA ARCHITECT: Jones&Henry aCONTRACTOR
F.A. Wilhelm Construction Co.,Inc. FAW Job#9548 a
3914 Prospect Street PROJECT NOS:
Indianapolis, N 46203
CONTRACT FOR: Interior Renovation CONTRACT DATE 1/1 1/201 l
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.
CONTRACTOR:
1. ORIGINAL CONTRACT SUM $ 19,870,000.00
2. Net change by Change Orders $ 174,296.00
3. CONTRACT SUM TO DATE(Line 1 t 2) $ 20,044,296.00 By:_�� /% � Date: 6/7/2012
4. TOTAL COMPLETED&STORED TO $ 19,963,442.00
DATE
(Column G on G703) State of: Indiana County of Marion � 1
5. RETAINAGE: Subscribed and sworn to before me this 7th day of June,2012
a. 10 °!o of Completed Work $ 1,000,695.55 Notary Public
(Column D+E on G703) My Commission expir : �j2tu` 201
b. 10 %of Stored Material $ 909.10 r cF
(Column F on G703) OWNER:
Total Retainage(Lines 5a+5b or By: Date:
Total in Column I of G703) $ 1,001,604.65 RESIDENT PROJECT REPRSENTATIVE:
6. TOTAL EARNED LESS RETAINAGE $ 18,961,837.35 By: Date:
(Line 4 Less Line 5 Total)
7. LESS PREVIOUS CERTIFICATES FOR
PAYMENT(Line 6 from prior Certificate) $ 18,725,458.35
8. CURRENT PAYMENT DUE $ 236,379.00
9. BALANCE TO FINISH,INCLUDING RETAINAGE $ 1,082,458.65 ARCHITECT'S CERTIFICATE FOR PAYMENT
(Line 3 less Line 6) In accordance with the Contract Documents,based on on-site observations and the data
comprising the application,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 entitled to payment of the AMOUNT CERTIFIED.
AMOUNT CERTIFIED...........$ 3CP4 31 Q O t7
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation if amount certified differs from the amount applied.Initial all figures on this
Total changes approved Application and onthe Continuation Sheet that are changed to conform with the amount certified.)
in previous months by Owner $162,093.00 $0.00 ARCHITEC .
Total approved this Month $12,203.00 $0.00 By: Date: (p
TOTALS $174,296.00 $0.00 This Certifi to is t negotiable. The A:IOIJNT CERTIFIED is payable only to the
Contractor named herein. Issuance,payment and acceptance of payment are without
NET CHANGES by Change Order $174,296.00 prejudice to any rights of the Owner or Contractor under this Contract.
AIA DOCUMENT 13702 APPLICATION AND CERTIFICATION FOR PAYMENT 1992 EDITION AIA.01992 THE AMERICAN INSTITUTE OF ARCHITECTS,1735 NEW YORK AVE.N.W..WASHINGTON,DC 200085292
VOUCHER # 121699 WARRANT # ALLOWED
T358284 IN SUM OF $
F A WILHELM CONSTRUCTION CO IN(
3914 PROSPECT ST
INDIANAPOLIS, IN 46203
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
17 07-1050-06 $236,379.00
Voucher Total $236,379.00
Cost distribution ledger classification if
claim paid under vehicle highway fund
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
T358284
F A WILHELM CONSTRUCTION CO INC Purchase Order No.
3914 PROSPECT ST Terms
INDIANAPOLIS, IN 46203 Due Date 7/26/2012
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
7/26/2012 17 $236,379.00
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
Date OKcer