216082 01/09/2013 CITY OF CARMEL, INDIANA VENDOR: 148000 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF TRANSPORTATION
i• `�o CARMEL, INDIANA 46032 100 N SENATE AVE,RM IGC-N 725 CHECK AMOUNT: $116.37
'y«o� INDIANAPOLIS IN 46204-2216 CHECK NUMBER: 216082
CHECK DATE: 1/9/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
202 4350900 17558 116 . 37 OTHER CONT SERVICES
INDIANA DEPARTMENT OF TRANSPORTATION
Driving Indiana's Economic Growth INVOICE
100 North Senate Avenue
Mitchell E. Daniels,Jr., Governor
Room IGC-N 725 Michael Cline, Commissioner
P-TA,, Indianapolis, Indiana 46204-2216
Customer No: CST000001811
Bill To: Invoice: 000017558
Invoice Date: 12/12/2012
City of Carmel Invoice Type: LPA
ATTN: Mike McBride
One Civic Square
Carmel IN 46032 AMOUNT DUE: $116.37
*** Payment is Due Upon Receipt of Invoice ***
Line Description Quantity Unit Amt Net Amount
1 Contract#: B-27185 1.00 116.37 116.37
Contract#: B-27185, Project#: 9929036, Change order#: 1 (see
attached).
Subtotal: 116.37
AMOUNT DUE: $116.37
- - - - - - - - - - - - - - - - - -
yen^*F� Purchase Order Order# Date Required Date Page
INDOT Chg Order Construction 0012802939 08/31/2011 01/11/2013 1 of 1
Y
Indiana Department of Transportation Requisition Number:0000060979
Approved by Encompass Leadership Team-2011 Vendor I D: 0000087456 RE M IT001
" B1s Agency: 00800 Indiana Dept of Transportation
Pay Terms: 35 Days in Arrears
# 1 CHANGE ORDER Fund/Object/Center: 63200/571620 /467030
Vendor 0000087456 REMIT001 1
SCHUTT-LOOKABILL CO, INC Ship To Dept Of Transportation
Remit to 4050 ROCKVILLE ROAD Construction Management Divisi
INDIANAPOLIS IN 46222 100 N SENATE AVE RM N925
INDIANAPOLIS IN 46204
SCHUTT-LOOKABILL CO, INC Bill To Indiana Dept of Transportation
Vendor 4050 ROCKVILLE ROAD Dept Of Transportation
Name INDIANAPOLIS IN 46222 Accounting
Address 100 N SENATE AVE RM N749
INDIANAPOLIS IN 46204
Vendor F Name: Buyer Name:Tepner,Roger-800
Contact--eMa!!: -- - -- - — -- eMail:- RTEPNER@indot.!N.gov — - --
Phone:
,. -
' �r.,�•:.>.: z:a"� >rw: t' °"' :''PPurch'as'e;Ordefoln"sfructions•&Comments'
20%LPA 80%FEDERAL.PO closed.change order 4.PE Chris Miller/Loveall
Cost Change#1
Ref Doc=RQ-0000082130 for$581.87(aw)12/12/12
LPA 80%FEDERAL.PO 0012802939. Final IC 642. PE/S Carroll Morgan.
="`;-r•. "T„.
P,urchase`O•rderL"ine;Details'
j„''-.;?: ?1.�?�. ...r•€,... ;” . 6 ^v r:• <3' s,�.. c" ..4:w, w�,.n
,; xs
Item`No: Descn tion„ *::;.., FOB Destination u;Ot" Ordered Unit Price'..'Eztended:'Amt
1- 1 B-27185-A NEW BRIDGE CONSTRUCTION 1.0000 0 EA 7,180.0000 7,180.00
GREENFIELD DISTRICT PCN:0300059
9929036 NEW BRIDGE STEEL
CONSTRUCTION HAMILTON COUNTY-ON
MONON TRAIL OVER CARMEL DRIVE
2- 1 Cost Change#1 B-27185-A NEW 1.0000 0 EA 581.8700 581.87
BRIDGE CONSTRUCTION GREENFIELD
DISTRICT PCN:0300059 9929036 NEW
BRIDGE STEEL CONSTRUCTION
HAMILTON COUNTY-ON MONON TRAIL
OVER CARMEL DRIVE
Deliveries acceptable only between 8:00 AM and 3:00 PM,Monday through Friday,excluding State
Holidays.
Pte' ,=Units: f<Measure Handlin �'Totals'.Si°natures:. ��/ W, � '�`��"'t
The following UN/CEFACT Unit of Measure
Common Codes are used in this document:
EA Each
This area left blank
Total PO Amt. $ 7,761.87
Issued by the Indiana Department of Transportation CONFIRMATION OF RECEIPT
I certify that the items listed above were received. All commodities appeared to conform to
specifications and showed no patent defects except as otherwise noted.
Signature of State Employee Receiver Date Signed(Month/Day/Year)
FUNDING ENCUMBERED BY THE AUDITOR OF STATE
I certify that there is sufficient unencumbered balance in the above account to cover the amount of this order,and that funds have been set aside for payment thereof.
Illlll IIIII IIIII IIIII 111111111 111111111111111111111111 II1111111111111111111111111111 1111 IN Indiana Department of Transportation
00800 0012802939
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 service rendered, by whom,
rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
INDOT Purchase Order No.
100 N Senate Ave, Room IGC-N 725 Terms
Indianapolis, IN 46204-2216 Date Due
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s) Amount
12/12/2012 17558 CCNT Change Order LPA share $ 116.37
Total $ 116.37
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 5-11-10-1.6.
20
Clerk-Treasurer
VOUCHER NC WARRANT NO.
INDOT 46 : ALLOWED 20
100 N Senate Ave, Room IGC-N 725 IN SUM OF $
Indianapolis, IN 46204-2216
$ 116.37
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO#or INVOICE NO. ACCT#/TITL AMOUNT
DEPT# I hereby certify that the attached invoice(s),
0 17558 202-509 s 116.37 or bill(s) is (are)true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
1/7/2013
Signature
City Engineer
Cost Distribution ledger classification if Title
claim paid motor vehicle highway fund