HomeMy WebLinkAboutJ.R. Clancy - $1,425Exhibit 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 terns and conditions of the Agreement, the other Loan
Documents, and the Disbursement instructions.
Purpose of Authorized Disbursement
Amount of Authorized Disbursement
Amount to be paid by Village Financial LLC
Application 1 (Angela Painting) October 2012
$1,425.00
Total Authorized Disbursement
$1,425.00
All 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 Len .. r and Village Financial, LLC.
Dated: I ( 20 1't
CITY OF CARMEL REDEVELOPMENT
CO SSION
By
Printed
Title 1--a 7 /uir /,f rrC7o/t_
LAS s. OLpS
Draft
Theater Equipment
Angela Painting (Mercantile)
October 2012
Amount to be paid by Village Financial $ 1,425.00
APPLICATION AND CERTIFICATION FOR PAYMENT
AIA DOCUMENT G702
PAGE ONE OF TWO
TO OWNER:
Village Financial, I.LC
770 3rd Avenue SW
Carmel, IN 46032
FROM CONTRACTOR: Angela Painting
8535 Twin Point Circle
Indianapolis, IN 46236
(317) 2811648
PROJECT: East Retaining Wall
Cannel, Indiana 46032
VIA CONSTRUCTION MANAGER:
Signature Construction, LLC
720 Third Avenue, SW
Carmel, Indiana 46032
APPLICATION NO:
1 Distribution to:
OWNER
ARCHITECT
PERIOD TO: 10/31/2012 CONTRACTOR
x
PROJECT NO:
CONTRACT DATE:
9/17/2012
CONTRACTOR'S APPLICATION FOR PAYMENT
Apptication is made for payment, as shown below, in connection with the Contract.
Continuation Sheet, AIA Document G703, is attached
I. ORIGINAL CONTRACT SUM
2. Net change by Change Orders
3. CONTRACT SUM TO DATE (Line 1 ± 2)
4. TOTAL COMPLETED & STORED TO DATE
5. RETAINAGE:
a. 5 % of Completed Work
(Column D + E on 0703)
b. 5 % of Stored Material
(Colman F on G703)
Total Retainage (Lines Sa 5b or
Total in Column I of 0703)
6. TOTAL EARNED LESS RETAINAGE
(Line 4 I.ess Line 5 Total)
7. LESS PREVIOUS CERTIFICATES FOR
PAYMENT (Line 6 from prior Certificate)
8. CURRENT PAYMENT DUE
9. BALANCE TO FINISH, INCLUDING RETAINAGE
(Line 3 less Line 6)
$
$
$
5
1,500.00
0.00
1,500.00
1.500.00
'The undersigned Contractor certifies that to the best 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 for which previous Certificates for Payment were issued and
payments received from the Owner, and that current payment shown herein is now due.
75.00 Subscribed and sworn to before me this
0.00
,. 41.w so. s .a.
KRISTI TAYLOR
Nntary t l T
_ IE�l IFICAT FOR PAYMEN
75 00 �NGIN� � ,�..'.
t
day of
Date:
I4/
Lt
1,425.00
0.00
1,425.00
75.00
CHANGE ORDER SUMMARY
ADDITIONS
DEDUCTIONS
Total changes approved
in previous Change Orders
$0.00
$0.00
Total approved this Change Order
$0.00
$0.00
TOTALS
$0.00
$0.00
NET CHANGES by Change Order
$0 00
accM RiFiii>t,h/R& tt l9 base on on -sire observations and the data
odiiiisitatke t -41 t;l 4t the Owner that to the hest of the
Engineer'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
$
(Attach explanation if amount certified differs from the amount applied. htiria! ail figures en tJii.
Application and onthe Crmtinaatinn Sheet that are changed to conform with the 071101971 certifier
ENGINEER:
By:
Date:
This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
Contractor named herein. issuance, payment and acceptance, of payment are without
prejudice to any rights of the Owner or Contractor ender this Contract.
AIA DOCUMENT 0702 • APPLICATION AND CERTIFICATION FOR PAYMENT 1992 EDITION • AIA • D1553 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE., N.W.. WASHINGTON, DC 20006 -5252
Users may obtain validation of this document by requesting a completed AIA Document 0401 - Certification of Document's Authenticity from the Licensee.
G703 CONTINUATION SHEET
To:
Signature Construction, EEC
720 Third Avenue, SW
Carmel, Indiana 46032
From:
Angela Painting
8535 Twin Point Circle
indianapnlis, EN 46236
Project:
East Retaining Wall
Carmel, Indiana 46032
Application No. :
Application Date:
Period To:
Engineer's Prnjccl No. :
Page 2 of 2
1
10/31/12
A
B
C
D E
F
G
A
1
Work Completed
Materials
Total
Presently
Completed
Balance
Retatnage.
Item
Scheduled
From Presinus
Stored
aid Stored
%
To
If
#
Description of Work
Value
S iicarinn
This Period
(Norio
To Date
(G /C)
Finish
Variable
D or E)
(D +E +F)
(C.G)
1
Painting
1,500.00
(1.00
1,500.00
0.09
1,500.00
100%
0.00
75.00
0.00
0.00
0.00
0.09
#D1V /01
0.00
0.00
0.00
0.00
0.00
0.00
#D1V /0!
0.00
0.1)0
0.00
0.00
0.00
0.00
#DtV /0!
11.00
0.00
0.00
0.00
0.00
0.00
#DIVJO!
0.00
0.00
0.00
0.09
0.00
0.00
#131V /0!
0.00
0.1)0
0.00
0.00
0.00
0.00
#DIV/0!
0.00
0.00
1,500.00
0.00
1,500.00
0.00
1,500.00
100%
0.00
75.00
I /we have a contract with
to provide
PARTIAL CONDITIONAL WAIVER
(other contracting party)
for the improvement of the property described as:
//-
And by signing this waiver waive my /our construction lien to the amount of $ f '% 5 . f
. for labor /materials provided through i cy,2s -1, �-
(date of draw cutoff or actual payment)
This waiver, together with all previous waivers, if any, (circle one) does /does not cover
all amounts due to me /us for contract improvement provided through the date shown
above. This waiver is conditioned on actual payment of the amount shown above.
If improvement is provided to property that is a residential structure and if the owner or
lessee of the property or the owner's or lessee's designee has received a notice of
furnishing from me /one of us, or if I /we are not required to provide one, and the owner,
lessee, or designee has not received this waiver directly from me /one of us, the owner,
lessee, or designee may not rely upon it without contracting me /one of us, either in
writing, by telephone, or personally, to verify that it is authentic.
Signed on: l �J
111 v
ktlid 4,1
(prirfted name of lien claimant)
Po m4 if rt es"
(sigrdature of lien claimant)
Address: g . -23 Y 6,0; Po;1,(Ve_
//43 Ve)
Telephone: /7 2 8/ 76 Li/'
DO NOT SIGN BLANK OR INCOMPLETE FORMS. RETAIN A COPY.