211428 07/31/2012 - CITY OF CARMEL, INDIANA VENDOR: 00350916 Page 1 of 1
ONE CIVIC SQUARE PRELOAD INC CHECK AMOUNT: $6,000.00
y�,�,•?o CARMEL,INDIANA 46032 839 STEWART AVENUE
GARDEN CITY NY 11530 CHECK NUMBER: 211428
CHECK DATE: 7/31/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
609 5023990 13 6, 000 . 00 1052 . 00
5 �'� TM APPROVED BY OWNER:
Document G702 - 1992
By: Date:
Application and Certificate for Payment
TO OWNER: PROJECT: Carmel. IN APPLICATION;NO: Distribution to:
City of Carmel, IN 700013
One Civil Square
One(1) MG Cl Tank PERIOD TO: 5/31/2012 OWNER
Water Treatment Plant a ant t No No. 1 El
Carmel,IN 46032 Contract 50B CONTRACT FOR:
ARCHITECT ❑
FROM CONTRACTOR: Preload Inc. VIA ARCHITECT: CONTRACT DATE: CONTRACTOR El
60 Commerce Drive PROJECT NOS: I0.PD.f05 / FIELD ❑
Hauppauge,NY 11788-3929
OTHER ❑
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information
Application is made for payment,as shown below,in connection with the Contract. and belief the Work covered by this Application for Payment has been completed in accordance
Continuation Sheet,AIA Document G703,is attached. 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
1.ORIGINAL CONTRACT SUM ................................................. $ 891 0000 that current payment shown herein is now due.
2. Net change by Change Orders .......................................... $ , CONTRACTOR: Preload Inc.
3.CONTRACT SUM TO DATE(Line 1 ±2) ..................................... $ By: Date: 5/3(>/t
Z
4.TOTAL COMPLETED&STORED TO DATE(Column G on G703) ...... $ State of: New Na y M.Coll,Secretarytrreasurer
5.RETAINAGE: County of: Su o
a. �.&of Completed Work Subscribed and sworn to before
(Column D+E on G703) $ 57,716.02 me this day of CATHY A. ZOLDAK
b. %of Stored Material 30 Ma 2012 Notary Public, State of tNew:York 'fit
v ,� .�,�,,nQ�' No. 01 ZO4996607 �
(Column F on G703) $ Notary Public: CL 1 1XJtk Certificate in Suffoik County
My Commission expires: �'1� Commission Expiras,May 18, ZG1%�f
Total Retainage(Lines 5a+5b or Total in Column I of G703)....... $ 577160
6.TOTAL EARNED LESS RETAINAGE .................................... $ 77 ARCHITECT'S CERTIFICATE FOR PAYMENT ,
(Line 4 Less Line 5 Total) In accordance with the Contract Documents,based on on-site observations and the data comprising
7.LESS PREVIOUS CERTIFICATES FOR PAYMENT ...................... $ this application,the Architect certifies to the Owner that to the best of the Architect's knowledge,
(Line 6 from prior Certificate) 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
8.CURRENT PAYMENT DUE ............................................. $ 6,000.06 AMOUNT CERTIFIED.
9.BALANCE TO FINISH,INCLUDING RETAINAGE AMOUNT CERTIFIED .............................................................................. $ (01 6900. Q
(Line 3 less Line 6) $ 57,716.02 (Attach explanation if amount certified differs faint the amount applied. /nitial all figures on this
Application and on the Continuation Sheet that are changed to conform with the amount certified.)
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHITECT:
Total changes approved in previous months by Owner $ 19 150.79 $ -24,350.0 By: AAJ Date: (Q, 2, 2
Total approved this Month $ $ This Certific e is Jot negotiable.The AMOUNT CERTIFIED is payable only to the Contractor
TOTALS $ $ named herein.issuance,payment and acceptance of payment are without prejudice to any rights of 1911-50- 79
NET CHANGES by Change Order $ _ the Owner or Contractor under this Contract.
CAUTION:You should sign an original AIA Contract Document,on which this text appears in RED.An original assures that changes will not be obscured.
AIA Document G702TM—1992.Copyright @ 1953,1963,1965,1971,1978,1983 and 1992 by The American Institute of Architects.All rights reserved.WARNING:This AIA® Document is protected by U.S.Copyright Law
and International Treaties.Unauthorized reproduction or distribution of this AIA® Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent
possible under the law.Purchasers are permitted to reproduce ten 0 0)copies of this document when completed.To report copyright violations of AIA Contract Documents,e-mail The American Institute of Architects'legal
counsel,copyright @aia.org.
_ TM
== Document G702 -
o 1992 Instructions
Application and Certificate for Payment
GENERAL INFORMATION
Purpose and Related Documents
AIA Document G702, Application and Certificate for Payment, is to be used in conjunction with AIA Document
G703,Continuation Sheet.These documents are designed to be used on a Project where a Contractor has a direct
Agreement with the Owner. Procedures for their use are covered in AIA Document A201, General Conditions of the
Contract for Construction.
Use of Current Documents
Prior to using any AIA Contract Document, users should consult www.aia.org or a local AIA component to verify the
most recent edition.
Reproductions
This document is a copyrighted work and may not be reproduced or excerpted from without the express written
permission of the AIA.There is no implied permission to reproduce this document, nor does membership in The
American Institute of Architects confer any further rights to reproduce this document.
The AIA hereby grants the purchaser a limited license to reproduce a maximum of ten copies of a completed G702,
but only for use in connection with a particular project.The AIA will not permit reproduction outside of the limited
license for reproduction granted above,except upon written request and receipt of written permission from the AIA.
Rights to reproduce the document may vary for users of AIA software. Licensed AIA software users should consult
the End User License Agreement(EULA).
To report copyright violations of AIA Contract Documents, e-mail The American Institute of Architects'legal
counsel, copyright @aia.org.
COMPLETING THE G702 FORM
After the Contractor has completed AIA Document G703, Continuation Sheet, summary information should be
transferred to AIA Document G702,Application and Certificate for Payment.
The Contractor should sign G702,have it notarized, and submit it, together with G703,to the Architect.
The Architect should review G702 and G703 and, if they are acceptable,complete the Architect's Certificate for
Payment on G702.
The Architect may certify a different amount than that applied for,pursuant to Sections 9.5 and 9.6 of A201.The
Architect should then initial all figures on G702 and G703 that have been changed to conform to the amount certified
and attach an explanation.The completed G702 and G703 should be forwarded to the Owner.
MAKING PAYMENT
The Owner should make payment directly to the Contractor based on the amount certified by the Architect on AIA
Document G702, Application and Certificate for Payment.The completed form contains the name and address of the
Contractor. Payment should not be made to any other party unless specifically indicated on G702.
EXECUTION OF THE DOCUMENT
Persons executing the document should indicate the capacity in which they are acting(i.e., president, secretary,
partner,etc.)and the authority under which they are executing the document. Where appropriate, a copy of the
resolution authorizing the individual to act on behalf of the firm or entity should be attached.
AIA Document G702TM—1992.Copyright @ 1953,1963,1965,1971,1978, 1983 and 1992 by The American Institute of Architects.All rights reserved.
WARNING:This AIA®Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this
AIA®Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible
under the law.Purchasers are permitted to reproduce ten(10)copies of this document when completed.To report copyright violations of AIA Contract
Documents,e-mail The American Institute of Architects'legal counsel,copyright @aia.org.
VOUCHER # 121719 WARRANT # ALLOWED
350916 IN SUM OF $
PRELOAD INC
839 STEWART AVENUE
GARDEN CITY, NY 11530
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
13 07-1052-00 $6,000.00
CO n1ljech'0
Voucher Total $6,000.00
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
350916
PRELOAD INC Purchase Order No.
839 STEWART AVENUE Terms
GARDEN CITY, NY 11530 Due Date 7/27/2012
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
7/27/2012 13 $6,000.00
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
Date �Pfficer