212574 09/12/2012 CITY OF CARMEL, INDIANA VENDOR: T358284 Page 1 of 1
0 ONE CIVIC SQUARE F.A.WILHELM CONSTRUCTION CO INC CHECK AMOUNT: $501,604.65
a CARMEL, INDIANA 46032 PO BOX 516
w off.; INDIANAPOLIS IN 46206 CHECK NUMBER: 212574
CHECK DATE: 9112/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
609 5023990 19 501, 604 . 65 OTHER EXPENSES
APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUME,NTc702 PAGE ONE OF 1 PAGES
TO OWNER: City of Carmel Board of Public Works APPLICATION NO: 19 RET Distribution to:
One Civic Square PROJECT: Cannel WTP#1 OWNER
Carmel, IN 46032 PERIOD TO 6/30/2012 F7ARCHITECT
FROM CONTRACTOR: VIA ARCHITECT: Jones&Henry CONTRACTOR
F.A. Wilhelm Construction Co., Inc. FAW Job#9548
3914 Prospect Street PROJECT NOS: El
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 Nvith 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:
I. ORIGINAL CONTRACT SUM S 19,870,000.00
2. Net change by Change Orders S 1 74,296.00 �/_� /)
3. CONTRACT SUM TO DATE(Line I t 2) S 20,044,296.00 By: L�a(Y�'l�s 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 this 9th day of.luly,2012
a. 10 %of Completed Work S 500,000.00 Notary Public:
(Column D+E on G703) My Commission expire .
b. 10 %ofStored Material S 0.00 AVV_4'_ S12ot�1
(Column F on G703) OWNER:
Total Retainage(Lines 5a+5b or By: Date:
Total in Column I of G703) S 500,000.00 RESIDENT PROJECT REPRSENTATIVE:
6. TOTAL EARNED LESS RETAINAGE S 19,544,296.00 By: Date:
(Line 4 Less Line 5 Total)
7. LESS PREVIOUS CERTIFICATES FOR
PAYMENT(Line 6 from prior Certificate) $ 19,042,691.35
8. CURRENT PAYMENT DUE S 501,604.65
9. BALANCE TO FINISH.INCLUDING RETAINAGE $ 500,000.00 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 �Q� ( ��-( (ps
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation i/amount certified differsfi•om the amount applied. Initial all frgrrres on this
Total changes approved Application and onthe Continuation 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 $0.00 This Corti sate i, not negotiable. The AMOUNT CERTIFIED is payable only to the
Contractor named herein. Issuance,payment and acceptance of payment are without
NE"T CHANGES by Change Orcler S174,296.00 prejudice to any 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,DC 20006-5249
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 9/10/2012
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
9/10/2012 19 $501,604.65
hereby certify that the attached invoice(s), or bill(s) is (are) true and
-orrect and I have audited same in accordance with IC 5-11-10-1.6
Date Officer
VOUCHER # 122100 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
19 07-1050-06 $501,604.65
VV
Voucher Total $501,604.65
Cost distribution ledger classification if
claim paid under vehicle highway fund