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211719 08/14/2012 CITY OF CARMEL, INDIANA VENDOR: T358284 Page 1 of 1 ONE CIVIC SQUARE F.A.WILHELM CONSTRUCTION CO INC CHECK AMOUNT: $80,854.00 CARMEL, INDIANA 46032 PO BOX 516 INDIANAPOLIS IN 46206 CHECK NUMBER: 211719 CHECK DATE: 8/14/2012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 609 5023990 18 80, 854 . 00 1050 . 06 APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT 6702 PAGE ONE OF 1 PAGES TO OWNER: City of Carmel Board of Public Works APPLICATION NO: 18 Distribution to: One Civic Square PROJECT: Carmel WTP#1 OWNER Carmel,IN 46032 PERIOD TO 6/30/2012 aARCHITECT FROM CONTRACTOR: VIA ARCHITECT: Jones&Henry CONTRACTOR F.A. Wilhelm Construction Co.,Inc. FAW Job 99548 3914 Prospect Street PROJECT NOS: Indianapolis, IN 46203 CONTRACT FOR:Interior Renovation CONTRACT DATE 1/11/2011 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%yhich 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 SUNI $ 19,870,000.00 2. Net change by Change Orders $ 174,296.00 3. CONTRACT SUM TO DATE(Line 1 f 2) $ 20,044,296.00 By: .VJIId? Date: 7/9/2012 4. TOTAL COMPLETED&STORED TO $ 20,044,296.00 DATE (Column G on G703) State of: Indiana County of: Marion 5. RETAINAGE: Subscribed and sworn to before me his 9th day of July,2012 a. 10 %of Completed Work S 1,001,604.65 Notary Public: (Column D+E on 6703) My Commission expires: b. 10 %of Stored Material S 0.00 �`� 5t ►`I (Column F on G703) OWNER: Total Retainage(Lines 5a+5b or By: Date: Total in Column I of G703) S 1,001,604.65 RESIDENT PROJECT REPRSENTATIVE: 6. TOTAL EARNED LESS RETAINAGE $ 19,042,691.35 By: Date: (Line 4 Less Line 5 Total) 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT(Line 6 from prior Certificate) $ 18,961,837.35 S. CURRENT PAYMENT DUE S 80,854.00 9. BALANCE TO FINISH,INCLUDING RETAINAGE $ 1,001,604.65 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.. . ........S CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (.41tach ejplanation ifamount certified differs from the amount applied Initial all figures on this Total changes approved Application and onthe Con till uatiaat Sheet that are changed to conform with the amount certified.) in previous months by Owner $174,296.00 $0.00 ARCHITE T: Total approved this Month 50.00 $0.00 By: Date: TOTALS $174.296.00 1 $0.00 This Certi I ate i. 1ot negotiable. The AMOUNT CERTIFIED is payable only to the t_:Ontractor named herein. Issuance,payment and acceptance of payment are wrthout NET CHANGES by Change Order 5174,296.00 prejudice to ally rights of the Owner or Contractor under this Contract. AIA DOCUMENT G702 APPLICATION AND CERTIFICATION FOR PAYMENT 1992 EDITION AIA ©1992 THE AMERICAN INSTITUTE OF ARCHITECTS.1735 NEW YORK AVE..N,W.,WASHINGTON,CC 20006-5292 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 8/7/2012 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 8/7/2012 18 $80,854.00 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 i Date fficer VOUCHER # 121725 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 18 07-1050-06 $80,854.00 CeNNCct C) Voucher Total $80,854.00 Cost distribution ledger classification if claim paid under vehicle highway fund