211629 08/14/2012 CITY OF CARMEL, INDIANA VENDOR: 00353347 Page 1 of 1
ONE CIVIC SQUARE ATLAS EXCAVATING INC CHECK AMOUNT: $53,187.50
CARMEL, INDIANA 46032 4740 SWISHER ROAD BLDG A
WEST LAFAYETTE IN 47906 CHECK NUMBER: 211629
CHECK DATE: 8/14/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
610 5023990 5 53 , 187 . 50 OTHER EXPENSES
APPLICATION FOR PAYMENT NO. 4
To: CITY OF CARMEL,IN (OWNER)
From: ATLAS EXCAVATING,INC. (CONTRACTOR)
Contract:
Project: COLLEGE AVENUE WATER TRANSMISSION MAIN-CAIL'1IEL,IN
OWNER's Contract No. 66E ENGINEER's Project
For Work accomplished through the date of: 6/30/2012
1 Original Contract Price: $ 1,421,157.50
2 Net change by Change Orders and Written Amendments or
3 Current Contract Price(1 plus 2): $ 1,421,157.50
4 Total completed and stored to date: $ 1,697,439.47
5 Retainage(per Agreement):
0.59%%of completed Work $ 10,000.00
including stored material
Total Retainage: $ 10,000.00
6 Total completed and stored to date less retainage(4 minus 5): $ 1,687,439.47
7 Less previous Application for Payments: $ 1,634,251.97
8 DUE THIS APPLICATION(6 MINUS 7): $ 53,187.50
Accompanying Documentation:
CONTRACTOR'S Certification:
The undersigned CONTRACTOR certifies that(1)all previous progress payments received from OWNER on account of
Work done under the Contract referred to above have been applied on account to discharge CONTRACTOR's legitimate
obligations incurred in connection with Work covered by prior Applications for Payment numbered 1 through 3 inclusive;(2)
title of all Work,materials and equipment incorporated in said Work or otherwise listed in or covered by this Application for
Payment will pass to OWNER at time of payment free and clear of all Liens,security interests and encumbrances(except such
as are covered by a Bond acceptable to OWNER indemnifying OWNER against any such Lien,security interest or
encumbrance);and(3)all Work covered by this Application for Payment is in accordance with the Contract Documents and
not defective.
Dated June 2S,2012 Atlas Excavating,Inc.
CONTRACTOR
`\ �/
\\�x� PB E T/-/,q �i, Tina Dillon, President
State of Indiana
Acono s
County of Tippecanoe
Subscribed and sworn to before me this 28th
day of June,2012 _ F of Z
rz
/
4A I�N �i�i/ACC O.,(0 I2o 11_3_�P
Notary PLAk Elizabeth A.Golden �'%��� NU%t -�������
Nly Commission expires: April 10,2013
Payment o I'T DUE THIS APPLICATION is recommended
B Bv:
ENGINEER(Authorized Signature) OWNER(Authorized Signature)
Title: Title:
Date: & Date:
EJCDC No. 1910-8-E (1996 Edition)RUS-WEP(2000)
Prepared by the Engineers Joint Contract Documents Committee and endorsed by The Associated General Contractors of America and the Construction Specification Institute.
VOUCHER # 121826 WARRANT # ALLOWED
00353347 IN SUM OF $
ATLAS EXCAVATING INC.
4740 SWISHER ROAD BLDG A
WEST LAFAYETTE, IN 47906
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
5 06-1050-74 $53,187.50
Availability
Voucher Total $53,187.50
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
00353347
ATLAS EXCAVATING INC. Purchase Order No.
4740 SWISHER ROAD BLDG A Terms
WEST LAFAYETTE, IN 47906 Due Date 8/9/2012
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
8/9/2012 5 $53,187.50
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�
Date icer