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214788 11/20/2012 CITY OF CARMEL, INDIANA VENDOR: 00350916 Page 1 of 1 ONE CIVIC SQUARE PRELOAD INC CARMEL, INDIANA 46032 839 STEWART AVENUE CHECK AMOUNT: $57,716.02 GARDEN CITY NY 11530 CHECK NUMBER: 214788 CHECK DATE: 11/20/2012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 609 5023990 700014 57, 716 . 02 OTHER EXPENSES off I Document G702TM - 1992 i Application and Certificate for Payment TO OWNER: City of Carmel IN PROJECT: Carmel. IN APPLICATION NO Di City One(1)4,0 MG Cleanvell Tank 700014 One Ciw l Square PERIOD TO 10/1 1/2012 OWNER ❑ Water Treatment Plant No. Carmel, IN 46032 Contract 50B CONTRACT FOR: ARCHITECT ❑ FROM CONTRACTOR: VIA ARCHITECT: Preload Inc, CONTRACT DATE: CONTRACTOR 0 49 Wireless Blvd PROJECT NOS: 10.I'D.165 / FIELD ❑ Hauppauge, NY 1 1788-3929 OTHER O I 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 AIA Document G703TM,Continuation Sheet,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....................... ;....................... $ gg 1 000 on that current payment shown herein is now due. 2.NET CHANGE BY CHANGE ORDERS ................ $ s ,�a ,, CONT TOR: Preload nc. r� 3.CONTRACT SUM TO DATE(Line 1.f 2). .... $ By: Date: VV 2- 4.TOTAL COMPLETED$STORED TO DATE(Column G on G703) ...... $ State of: New •rk ancy M: ll Secretarylrreasurer 5.RETAINAGE: County of: Suffolk a• %of Completed Work Subscribed and sworn to_before !' CATHY A. ZOLDAK (Col(mns D+°E on G703) $ me this da of Notar Public, State of New York b, °/a of Stored Material 11 October,2012 y Y No.01 Z04996607 , t Column Fon G703 $ Notary Public: t7 (� Certificate in Suffolk County (Column ry �`�� Commission Expires May 18, Zol My commission expires: �y Total Retainage(Lines 5a+5b,or Total in Column!of G703)...... $ 000 6.TOTAL EARNED LESS RETAINAGE .................................... S RRS a;nn 79 ARCHITECT'S CERTIFICATE FOR PAYMENT (Line 4 minus 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, 82-8- sz4.77 information and belief the Work has progressed as indicated, the quality of the Work is In (Line 6 from prior Certifcaie) accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT CERTIFIED. I 8.CURRENT PAYMENT DUE .............. 57 716.02 9.BALANCE TO FINISH,INCLUDING RETAINAGE ' AMOUNT CERTIFIED ................................. ............. (Line 3 minus Line 6) $ „� (Attach explanation ifcrmount cert ed d ua fiorrz the arnoznrt applied irrltial al/fgures on this °°— Application and on the Continuation Sheet,that sire changed to conform with the amount certified) j CHANGE ORDER SUMMARY . ADDITIONS DEDUCTIONS ARCHITEC Total changes approved,ui previous months by Owner S 19,150.79 $ -24,350.00 BY �tJ Date: /©—/')�-/2 otal approved this month $ $ This Cert' cat not negotiable.�The AMOUNT CERTIFIED is payable only to the Contractor TOTAL _ $ named herein issuance;payment and acceptance of payment are without prejudice to any rights of ET CHANGES b Change Order $ the Owner or;; r Cottractor 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 G70211-1992.Copyright ©1953,1963,1965,1971,1978,1983 and 1992 by The American Institute of Architects.All rights reserved.WARNING:This AIAO 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 Americas i .,.• counsel,copyright @aia.org. r now 1A Document G702 - 1992 Instructi TM ors Application and Certificate for Payment GENERAL INFORMATION Purpose and Related Documents. AIA Document G702TM-1992,Application and Certificate for Payment, is to be used in conjunction with AIA Document G703TM,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 TM,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 G702 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. EXECUTING 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 firth or entity should be attached. AIA Document G702 T" —1992.Copyright @ 1953,1963,1965,1971,1978,1983 and 1992 by The American Institute of Architects.All rights reserved. WARNING:This AIO 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. 010711ACD44 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 11/14/2012 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 11/14/201, 700014 $57,716.02 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 6,V,cer VOUCHER # 122769 WARRANT # ALLOWED 350916 IN SUM OF $ PRELOAD INC 839 STEWART AVENUE GARDEN CITY, NY 11530 Carmel Water Utility ON ACCOUNT OF APPROPRIATION FOR t Board members PO# INV# ACCT# AMOUNT Audit Trail Code 700014 07-1050-06 $57,716.02 CG?NrUcC fdoti Voucher Total $57,716.02 Cost distribution ledger classification if claim paid under vehicle highway fund