HomeMy WebLinkAboutCoreslab Structures - $11,540Exhibit D
Disbursement Instructions
Mercantile Bank hereby is instructed to make a disbursement of Loan Proceeds from the
Borrower Loan Account to (or for the account of) Borrower in: (a) the amount of the "Total
Authorized Disbursement: line in the "Amount of Authorized Disbursement" column below;
and (b) accordance with the terms and conditions of the Agreement, the other Loan
Documents, and the Disbursement instructions,
Purpose of Authorized Disbursement
Amount of Authorized Disbursement
Coreslab Structures Appl. #1
$ 576.00
Coreslab Structures Appl. #2
$ 9,810.00
Coreslab Structures Appl. #3
$ 1.154.00
Total Authorized Disbursement
S11,540.00
AR terms used in these Disbursement Instructions without definition shall have the meanings
ascribed thereto in that certain Loan Agreement (PAC Equipment), dated, as of August 31, 2009,
by and between Lender and Village Financial, LLC.
Dated: 2 j 20//?
CITY OF CARMEL REDEVELOPMENT
COMMISSION
By
Printed Lt s OLO1
Title 1 k Reacie^
IJ3
APPLICATION AND CERTIFICATION FOR PAYMENT ANA Document G702
To Owner or General Contractor: Project: Application No.: 1 Revised
Signature Construction Cannel City Center Motor .application Date: 10/17/2012
720 3rd Avenue SW Court Stair Period To: 10/31/2012
Cannel, IN 46032 Mercantile's PAC Project No.: 12.022
From Contractor: Architect: Contract Date: 01/00/1900
Coreslab Structures (Indianapolis) Inc. Contract For: Precast Concrete
1030 S. Kitley Ave.
Indianapolis, IN 46203
Co t ies
to:
Owner
Architect- originals
General Contractor
SuhContractnr
Q
0
0
0
CONTRACTOR'S APPLICATION FOR PAYMENT
Contractor's Certificate for Payment
Application is made for Payment, as shown below, in connection with the Contract. Continuation
Sheet, AIA Document 0703 is attached.
The undersigned Contractor certifies that to the hest of the Contractor's knowledge, information and belief
the Work covered by this Application for Payment has been completed in accordance with the Contract
Documents, that all amounts have been paid by the Contractor for Work forwhich previous Certificates for
Payment tcere issued and pa}ments received front the Owner. and that current payment shown herein is
now due.
1. Original Contract Sum $ 11,540.00
2. Net change by Change Orders
$0.00
CONTRACTOR: Coreslab Structures (Indianapolis) Inc.
3. Contract Sum to Date (Line 1* 2)
$ 11,540.00
4. Total Completed 8t. Stored $ 640.00
PA•
(Column G on Detail Sheet)
By: �e ll Date: 10/17/2012
5. Retainage
a. 10% of Completed Work $ 64.00
-., _ — ;
put. few" "' "' `" :'
State of Indiana County of in tu
' '' "
(Column D + E on Continuation)
Subscribed and SW OM to before me on 1 E 7/2 12 i, ,i, ; /,,, ;. % ;,t p_. T;,. (;
b. 10% of Stored Materials $ -
if
Notary Public: Yff? Q.. i, X1.-4- ,1 diVATE, OF " -,.'
My Commission expires: `�f��f7 a �''�". �-y^ ,t,o =r`n
` a
..�.:--- __:- ..:..._. .......,,..._,.i
(Column F on Continuation)
Total Retainage Lines 5a + 5b
$ 64.00
6. Total Earned Less Retainage (Line 4 Less Line 5's Total)
$ 576 -00
Certificate for Payment
7. Less Previous Certificates for Payment
In accordance with the Contract Documents, based on on -site observations and the data
(Line 6 from prior Payment Request)
$ -
comprising the application, the Architect certifies to the Owner that to the best of the Architect's
8. Current Payment Due
S 576.00
knowledge, information and belief the Work has progressed as indicated, the quality of the
8a. Current Completed including Retainage
$ 640.00
Work is in accordance with the Contract Documents, and the Contractor is entitled to payment
8b. Retainage Being Held This Period
$ 64.00
of the Amount Certified. 4-,trr ._..._- --- - --
Amount Certified S •�) ft O
(Attach explanation if amount certified differs from the amount applied for. initial all figures 00 this
9. Balance to Finish including Retainage Being Held
$ 10,964.00
(Line 3 less Line 6)
;l- plrentinn and on the Continuation ,S'heet that are changed to nor form to the amount certified)
Change Order Summary
Additions
Deductions
Total approved in previous months
$0.00
$0.00
,.• ---�
r �,
ARCHITECT: t
t
Total approved this month
$0.00
$0.00
"., , A
By: / ...
Date: l !AA
:..�
the
Totals
$0.00
50.00
This `ertificate is ncit i igotiahle. The Amount Certified
named he I st a/tce, payment and acceptance of payment
is payable��6n(y to Contractor
are tvitRiout prejudice to any rights
of the Owner or Contractor under this Contract.
Net Changes by Chanz Order
AIA DOCUMENT G703
Project:
Carmel City Center Motor
Contract For:
Precast Concrete
A
B
C
Application No.: 1 Revised
Application Date: 10/17/2012
Period To: 10/31/2012
Project Number: 12.022
Contract Date:
Item
Description
Orignal Contract
Schedule Of Values
D
Previous Work
Completed &
Materials Stored
E 1 F
This Month
Work Completed
G
H
Materials Stored
Total Completed &
Materials Stored
Percent
Complete
Balance to Finish Retainage
Engineering
Production
Delivery
Erection /Field Services
Precast Stair Units
1,455.00
3,490.00
670.00
3,304.00
2,621.00
640.00
640.00
43.99"/o
0.00%
0.00%
0.00"%
0.00%
815.00
3,490.00
670.00
3,304.00
2,621.00
64.00
Subtotal
11,540.00
640,00
640.00
5.55%
10,900.00 64.00
Change Orders
0.00%
0.00 %io
..............
0.00%
Subtotal
GRAND TOTALS
11,540.00
640.00
0
640.00
5.55%
10,900.00 64.00
PARTIAL
WAIVER OF LIEN
(Payment to Follow)
State of Indiana Marion County ss:
WHEREAS The undersigned
employed by
Coreslab Structures (Indianapolis) Inc
(Name of Declarer)
has been heretofore
Signature Construction To furnish certain material
(Contractor)
and labor to:wit: Precast Concrete Pieces
(Work performed)
for the project: Carmel city Center Motor Court Stair
and located on Carmel, Indiana
(Exact Legal description and street address, if any, of the land on which
the improvement is situated or to which it may be removed)
NOW, THEREFORE, KNOW YE, that the undersigned, upon the receipt of Payment application # 1 in
the amount of ...
Five Hundred Seventy-six dollars and no /cents Dollars ($ 576.00)
It hereby and now waives and releases unto the said owner of said premises, any and all lien, right of lien or claim of whatsoever kind
or character on the above described building and real estate, TO AND FOR SAID AMOUNT, on account of any and all labor, material
or both, furnished for or Incorporated into said building by the undersigned, up to this date and further, he represents that no
other person or party has any right to a lien on account of any work performed or material furnished by said company. THIS PARTIAL
WAIVER OF LIEN has been given upon the promise to pay the amount as indicated on the attached statement or payment application.
Coreslab Structures (Indianapolis) Inc.
By: "71
J
VP/GM
(Name of Claimant firm)
(Authorized Representative) (Title)
STATE OF Indiana
COUNTY OF Marion
Before me, a Notary Public in and for said County and State, personally appeared Mpar 8 (kL(
who acknowledged the execution of the foregoing PARTIAL Waiver of Lien, and who, having been duly sworn, stated that the representations therein
ontained are true.
Ss:
Witness my hand and Notarial Seal this
Signature
Printed:
My commission expires:
County of Residence:
17m day of October 2012
Volere S. Hasseld
9117117
Hamilton
CPA S
dO" (AR Y P;441 if' 1
2. qs,
t :: !
APPLICATION AND CERTIFICATION FOR PAYMENT AIA Document G702
To Owner or General Contractor: Project: Application No.: 2
Sigiantre Construction Carmel City Center Motor Application Date: 11/28/2012
720 3rd Avenue SW Court Stair Period To: 12/31/2012
Carmel, IN 46032 Mercantile's PAC Project No.: 12.022
From Contractor. Architect: Contract Date: 01/00/1900
Coreslab Structures (Indianapolis) Inc. Contract For: Precast Concrete
1030 S. Kiticy Ave.
Copics
to:
Owner
Architect- originals
General Contractor
SuhContractor
1
0
0
0
Indianapolis, IN 46203
CONTRACTOR'S APPLICATION FOR PAYMENT
Contractor's Certificate for Payment
Application is made for Payment, as shown below, in connection with the Contract. Continuation
The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and belief
Sheet, AIA Document G703 is attached.
the Work covered by this .Application for Payment has been completed in accordance with the Contract
Documents, that all amounts have been paid by the Contractor for Work for which pre. •ions Certificates for
Payment were issued and payments received from the Owner, and that current pa;1ncnt shown herein is
now due.
1. Original Contract Sum $ 1 1,540.00
2. Net change by Change Orders
$0.00
CONTRACTOR: Coreslab Structures (Indianapolis) inc.
3. Contract Sum to Date (Line 1 ± 2)
$ 11,540.00
4. Total Completed & Stored $ 11,540.00
(Column G on Detail Sheet)
By: ef.(2vv-
Date:
11/28/2012
5. Retainage
a. 10% of Completed Work $ 1,154.00
State of Indiana County of RIP C•tcnJ
(Column D + F on Continuation)
Subscribed and sworn to before e on 1 28 012..::,___:... _
E
b. 10% of Stored Materials $ -
Notary Public: / i'J.— `, ..1A
.
:' "= "-
(Column F on Continuation)
��'
My Commission expires: Cl/ h 1r7 �
-? r:-h_ i,1- L:i:; f,,.:t,
Total Retainage Lines 5a + 5b
$ 1,154.00
-
6. 'Total Earned Less Retainage (Line 4 Less Line 5's Total)
$ 10,386.00
Certificate for Payment
7. Less Previous Certificates for Payment
In accordance with the Contract Doctmtenls, based on on -site observations and the data
(Line 6 from prior Payment Request)
$ 576.00
comprising the application, the Architect certifies to the Owner that to the best of the Architect's
8. Current Payment Due
$ 9,810.00
knowledge, information and belief the Work has progressed as indicated, the quality of the
8a. Current Completed Including Retainage
$ 10,900.00
Work is in accordance with the Contract Documents; and the Contractor is entitled to payment
8h. Retainage Being Held This Period
$ 1,090.00
of the Amount Certified. ,n.` ---"'l"
Amount Certified S - (
9. Balance to Finish Including Retainage Being Held
$ 1;154.00
(Attach explanation if amount certified di 'rs from the amou77r applied for= Inirrnl
all, rgures on this
(Line 3 less Line 6)
Application and on the ('r17n,7Natial7 Shea; that are changed to ccnfonn to the amount certified.)
Change Order Summary
Additions
Deductions
Total approved in previous months
$0.00
$0.00
ARCHITECT;`, 1:,; .
t; , I.. l
Total approved this month
$0.00
$0.00
Date:
4 �r_ iI r
R , ; t i(j 1� -'^"~h
'n t
Totals
$ 0.00
$0.00
7ihis Certificate is gotiehlc. The Amount Certified is payable only id the Contractor
Net Changes by Change Order
named herein. Issu ice, payment and acceptance of payment are without prejudice to any rights
of the 0-WilZ"t or lontractor under this Contract.
AIA DOCUMENT G703
Project:
Carmel City Center Motor
Contract For:
Precast Concrete
A
Item
Description
Orignal Contract
Engineering
Production
Delivery
Erection /Field Services
Precast Stair Units
Schedule Of Values
D
Previous Work
Completed &
Materials Stored
Application No.:
Application Date:
Period To:
Protect Number:
Contract Date:
G
2
11/28/2012
12/31/2012
12.022
This Month
Work Completed
Materials Stored
Total Completed &
Materials Stored
Percent
Complete
Balance to Finish Retainage
1,455.00
3,490.00
670.00
3,304.00
2,621.00
640.00
615.00
3,490.00
670.00
3,304.00
2,621.00
1 455.00 100.00%
3,490.00 100.00%
.. ...............................
670.00 100.00%
3,304.00 100.00%
2,621.00 100.00%
145.50
349.00
67.00
330.40
262.10
Subtotal
Change Orders
11,540.001 640.00
10,900.00
11,540,00
100.00%
1,154.00
2
f SubtotaI
0.00%
0.00%
0.00%
GRAND TOTALS 11,540.00
640.00
10,900.00
11,540.00
100.00%
0.00
1,154.00
0
PARTIAL
WAIVER OF LIEN
(Payment to Follow)
State of Indiana Marion County ss:
WHEREAS The undersigned
employed by
Coreslab Structures (Indianapolis) Inc
(Name of Declarer)
has been heretofore
Signature Construction To furnish certain material
(Contractor)
and labor to:wit: Precast Concrete Pieces
(Work performed)
for the project: Carmel city Center Motor Court Stair
and located on Carmel, Indiana
(Exact legal description and street address, if any, of the land on which
the improvement is situated or to which it may be removed)
NOW, THEREFORE, KNOW YE, that the undersigned, upon the receipt of Payment application # 2 in
the amount of ...
Nine Thousand Eight Hundred Ten dollars and no/ cents Dollars ($ 9,810.00)
It hereby and now waives and releases unto the said owner of said premises, any and all lien, right of lien or claim of whatsoever kind
or character on the above described building and real estate, TO AND FOR SAID AMOUNT, on account of any and all labor, material
or both, furnished for or incorporated into said building by the undersigned, up to this date and further, he represents that no
other person or party has any right to a lien on account of any work performed or material furnished by said company. THIS PARTIAL
WAIVER OF LIEN has been given upon the promise to pay the amount as indicated on the attached statement or payment application.
Coreslab Structures (Indianapolis) Inc.
By:
VP /GM
(Name of Claimant firm)
STATE OF Indiana
ss:
COUNTY OF Marion
(Authorized Representative) (Title)
Before me, a Notary Public in and for said County and State, personally appeared
MATT S LL P
who acknowledged the execution of the foregoing PARTIAL Waiver of Lien, and who, having been duly sworn, stated that the representations therein
ontained are true.
Witness my hand and Notarial Seal this
Signature
28t day of November 2012
9,7 24,
Volere S. Hasseld
Printed:
r
9117!17 i VOL E:=RE S. H.� S.S: ; �1 �
My commission expires:
NOTARY ra ;iti, y
Hamilton ( gF= •til
County of Residence: r STATE OF ° ,art,;., ■-
APPLICATION AND CERTIFICATION FOR PAYMENT AIA Document G702 _._. _
To Owner or General Contractor: Project: Application No.: C3 Retainage_.
Signature Construction Carmel City Center Motor Application Date: 1 1/28/2012
720 3rd Avenue SW Court Stair Period To: 12/31/2012
Carmel, IN 46032 Mercantile's PAC Project No.: 12.022
From Contractor: Architect: Contract Date: 01/00/1900
Coreslab Structures (Indianapolis) Inc. RECEIVED JAN 2 5e act For: Precast Concrete
u
1030 S. Kitley Ave.
Indianapolis, iN 46203
Copies
to:
Owner
Architect - originals
General Contractor
SubContractor
I
0
0
0
CONTRACTOR'S APPLICATION FOR PAYMENT
Contractor's Certificate for Payment
Application is made for Payment, as shown below, in connection with the Contract. Continuation
The undersigned Contractor certifies that to the hest of the Contractor's knowledge, information and belief
Sheet, AIA Document G703 is attached.
the Work covered by this Application for Payment has been completed in accordance with the Contract
Documents, that all amounts have hcen 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.
1. Original Contract Sum , 5 1 1,540.00
2. Net change by Change Orders
50.00
CONTRACTOR: Coreslab Structures (Indianapolis) Inc.
3. Contract Sum to Date (Line 1 ± 2)
5 11,54000
4. Total Completed & Stored $ 11,540.00
(Column G on Detail Sheet)
/ /
Date:
11/28/2012
By: , +.
- `�� ��
5. Retainage
State of Indiana County of 1'hA 1,01ti
Subscribed and sworn to before me on: l /2012
Notary Public: /ifti.h.t 4-Z-1 - ; � '
^�
:,-,..,-,::;',--D CPA
uift,
gl11l �� tyt�9.q-��
My Commission expires: r
,`
�( ;rr' *r•;:, • ,
` ' "'
Total from Retainage Column on Detail Sheet.
5'°
...: 1
6. Total Earned Less Rctainage (Line 4 Less Line 5's Total)
$ 11,540.00
Certificate for Payment � — - -•
7. Less Previous Certificates for Payment
In accordance with the Contract Documents; based on on -site observations and the data
(Line 6 from prior Payment Request)
5 10,386.00
comprising the application, the Architect certifies to the Owner that to the best of the Architect's
8. Current Payment Due
S 1,154.00
knowledge, information and belief the Work has progressed as indicated, the quality of the
8a. Current Completed Including Retainage
5 -
Work is in accordance with the Contract Documents, and the Contractor is entitled to payment
8h. Retainage Being Held This Period
5 (1,154.00)
of'the Amount Certified. ,l
} \ ■ __-_ -----
Amount Certified 5 i s ti
9. Balance to Finish Including Retainage Being Held
$ -
(Attach e.vplananan if amount certified d fcrs`finnr the applied for. Initial
all frgrors on this
(Line 3 less Line 6)
.mrowu
Application and on the Continuation Sheet that are changed to conform to the amount certified)
Change Order Summary
Additions
Deductions
Total approved in previous months
50.00
50.00
ARCHITECT: }\
Total approved this month
50.00
50.00
By: 1("------ ''; r. IA Ui \
Date:
A
Ii
Totals
50.00
$0.00
This Certifice. te. is not n iahlc. The Amount Certified is payable drily to ontractor
Net Changes by Change Order
named herein 'scan payment and acceptance of payment are vvithbui pr judice to any rights
of the Owner or Contractor under this Contract.
AIA DOCUMENT G703
Project:
Carmel City Center Motor
Contract For:
Precast Concrete
Application No.: 3 Retainage
Application Date: 11/28/2012
Period To: 12/31/2012
Project Number: 12 -022
Contract Date:
D
E F
G
Item
Previous Work
Description Schedule Of Values Completed &
Materials Stored
This Month
Work Completed Materials Stored
Total Completed &
Materials Stored
Percent
Complete
Balance to Finish
Retainage
Orignal Contract
Engineering 1,455.00 1,455.00
Production 3,490.00 3,490.00
Delivery 670.00 670.00
Erection /Field Services 3,304 00 3,304.00
Precast Stair Units 2,621.00 2,621.00
1,455 00 100.00%
3,490.00 100.00%
670.00 100.00%
3,304.00 100.00%
2,621.00 100.00%
Subtotal 11,540.00 11,540.00
Change Orders
Subtotal
11, 540.00
100.00%
0.00%
0.00%
0.00%
GRAND TOTALS
11,540.00
11,540.00
11,540.00 100.00%
0.00
0.00