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HomeMy WebLinkAboutGibraltar, Signature, Smock Fansler - $63,452.80 ye Regions 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. Amount of Authorized Disbursement Amount to be paid by Carmel Theater Development Company as per the Motor Court Improvements installment purchase contract Pay application 5(Gibraltar) May 2011 $ 12,424.50 Pay application 5(Signature) May 2011 $ 9,888.20 Pay application 2(Smock Fansler) May 2011 $ 36,052.20 Pay application 1 (Signature) May 2011 $ 5,087.90 Total Authorized Disbursement $ 63,452.80 All terms used in these Disbursement Instructions without definition shall have the meanings ascribed thereto in that certain Loan Agreement (Equipment and Improvements), dated July 22, 2010, by and between Regions Bank and Carmel Theater Development Company, LLC. Dated: G/ /( CITY OF CARMEL REDEVELOPMENT COMMI SION By: Les S. Olds Printed: Executive Director Title: It is acknowledged and agreed by the parties that CRC has reserved the right to require, as a condition of authorizing disbursement of Loan Proceeds from the Borrower Loan Account to (or for the account of) Borrower: (a) completion of a satisfactory inspection by CRC of the portions of the Equipment and/or the Improvements to which the disbursement relates; and (b) receipt of customary submittals. P5 Motor Court (Gibraltar) January 2011 Application 1 Paid by Carmel Theater Development $ 47,936.70 February 2011 Application 2 Paid by Carmel Theater Development $ 19,872.00 March 2011 Application 3 Paid by Carmel Theater Development $ 54,382.50 April 2011 Application 4 Paid by Carmel Theater Development $ 93,636.00 May 2011 Application 5 Amount to be paid by Carmel Theater Development $ 12,424.50 ® ��4—�I� Document G702IC MaTM - 1992 ,�.t- CL t I Application and Certificatefor Payment t Construction Manager-Adviser Edition _ _ . TO OWNER: Signature Cons_tiucuon PROJECT: Plaza Parcel 5:Phase 1,Carmel City Centre NO _':5'-4.;_r"` Distribution to: One Pedcot''Square-720 3rd Avenue SW PERIOD TO: u"°.0130/11- OWNER ❑ _Carmelc:IN-46032 - - CONSTRUCTION MANAGER ❑ FROM CONTRACTOR: Gibraltar Construction Corp VIA CONSTRUCTION:MANAGER:. C1 NTRACT DATE:4/1311p ARCHITECT ❑ 2932 N.Webster Ave. PROJECT NOS: I I CONTRACTOR ❑ Indianapolis,IN 46219 VIA ARCHITECT' ' Pedcor Design Group,LLC FIELD ❑ CONTRACT FOR: Waterproofing and Paving Components ❑ • CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and Application is made for payment,as shown below,in connection with the Contract belief the Work covered by this App'cation for Payment has been completed in accordance with the Contract Documents,that all am., n have been paid by the Contractor for Work for which previous Continuation Sheet,AlA Document G703,is_attached. Certificates for Payment were ..su , and payments received from the Owner, and that current 1.ORIGINAL CONTRACT SUM _ $ 253,613.00 payment shown erei is n w .1. c ion Cor ' 2.Net change by Change Orders ......' $ 0'W CONTRACTOR: Ibra�tar •` 253,613.00 r 3.CONTRACT SUM TO DATE(Line j1,-±,2)-,' $ By 4 /i►�� = Date: _j 4 /l 4.TOTAL COMPLETED 8 STORED TO�DATE(Column G on G703) $ 203,613.00 T State of: %/ �'� ` R1AN M ID 5:RETAINAGE: __. _ =-' County of 1_ , a s ►���:.F B R. CBR E �� ° ✓ ' . Res. o� Na;icock County a. 4 of;C-oonleted Work 25,361.30 Subscribed.and .,. totigO -. My Comm. 11- - / • o// �- Y Exp. 29-2017 (Colwnd D+Eon G703) $ me this -� .yo. ...67410111.14 Commission #611862 b.. -_ %of Stored Material Notary Public: ...„'.- (Column F on G703) $ My Commission expires: //' '' Total Retainage(Lines 5a+5b or Total in Column I of G703).. $ CERTIFICATE FOR PAYMENT 228,251.70 In accordance with the Contract Documents,based on on-site observations and the data comprising 6.TOTAL EARNED LESS RETAINAGE S this application,the Construction Manager and Architect certify to the Owner that to the best of their (Line 4 Less Line 5 Total) knowledge,information and belief the Work has progressed as indicated,the quality of the Work is in 215,827.20 accordance with the Contract Documents,and the Contractor is entitled to a 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT $ payment of the AMOUNT (Line 6 from prior Certificate) CERTIFIED' 8.CURRENT PAYMENT DUE _ $ 12,424.50 AMOUNT CERTIFIED $ 12-4011..5n _ 9rBALANCE TO FINISH,INCLUDING RETAINAGE - ``' (Attach explanation if amount certified differs from the-an uat.applied.Initial all figures on this = 25,361.30 Application and on the Continuation Sheet that are changed'to conform with the amount certified.) (Line 3 less Line 6) -_: $ CONSTRUCTION NAG f -- _ c ' -_ , By: �i� _ = Date: r/t t CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHITECT: -:... Wiz'.,[ . p tic Total changes,appioved to previous months by Owner $ $ B $ ' y� � � . �.l�i >i■_ Date: Total approved this Month $ $ This Certificate isr._it_negoti.•.le. The AMOUNT CER 1 IMhD is paya a on. to the Contractor TOTALS $ $ named h�e in. ssuance payment and acceptance o meat without preju 'ce to any rights of NET CHANGES by Change Order $ the Owne ontractor'under this Contract. -1 6X., 6f3ffq CAUTION:You should sign an original AlA Contract Document,on which this text a'pears in RED.An original assures that changes will not be obscured- AIA Document G7OVCMarr-1992.Copyright 0 1992 by The American Institute of Architects.All rights reserved.WARNING:This AIA°Document is protected by US.Copyright Law and international Treaties. Unauthorized reproduction or distribution of this Ate 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 AlA Contract D meats,e-mail The American Institute of Architects'legal counsel,copyright@aia.org. P /nv Director of Redevelopment y60ecdS I CONTINUATION SHEET Page 2 of 2 APPLICATION AND CERTIFICATE FOR PAYMENT,containing Contractor's signed Certification,is PPLI ATION NO. TE: 5 attached. In tabulations below,amounts are stated to the nearest dollar. Use Column I on Contracts where APPLICATION DATE: 5/30/2011 variable retainage for line items may apply. PERIOD TO: 5/30/2011 ARCHITECTS PROJECT NO. : A B C D I_ E F G H I WORK COMPLETED MATERIALS TOTAL ITEM FROM PREVIOUS PRESENTLY COMPLETED AND % BALANCE TO RETAINAGE DESCRIPTION OF WORK SCHEDULED VALUE FINISH (IF VARIABLE NO. APPUCATION THIS PERIOD STORED(NOT IN STORED TO DATE (G 1 C) (D+E) D OR E} (D+E+F) (C-G) RATE) 1 Supervision $1,000.00 $850.00 $150.00 $1,000.00 100°% - 100.00 2 Trench Drain Material $7,500.00 $7,500.00 $7,500.00 100% - 750.00 3 Trench Drain Labor $1,500.00 $1,500.00 r _ $1,500.00 100% - 150.00 4 Concrete Topping Slabs&Curbs Mt'I $60,000.00 $58,800.00 $1,200.00 $60,000.00 100% - 6,000.00 5 ,Concrete Topping Slabs&Curbs Labor _ $69,213.00 $67,828.00 $1,385.00 $69,213.00 100% - 6,921.30 _ 6 Waterproofing&Expansion Joints $107,000.00 $96,300.00 $10,700.00 $107,000.00 100% - 10,700.00 7 Plumbing $7,400.00 $7,030.00_ $370.00 _ $7,400.00 100% - 740.00 , , $253,613.00 $239,808.00 $13,805.00 $0.00 $253,613.00 100% $0.00 $25,361.30 ISA Form#1-402 AFFIDAVIT AND WAIVER OF LIEN ❑ FINAL ® PARTIAL ® PAYMENT TO FOLLOW State of Indiana, County of Marion, SS Michael Smith being duly sworn state that he is the President of Gibraltar Construction Corp having contracted with the Owner to furnish certain materials and/or labor for a project known as Carmel City Cntr-P111 -Waterproofing and Paving Components-Motor Court and owned by Carmel Theater Development Company. and does hereby further state on behalf of the aforementioned contractor: (PARTIAL WAIVER)that there is due from the Owner the sum of Twelve Thousand Four Hundred Twenty Four and 50/100 Dollars ($12,424.50) ❑ receipt of which is hereby acknowledged; or ® the payment of which has been promised as the sole consideration of this Affidavit and Partial Waiver of Lien which is given solely with respect to said amount, and which waiver shall be effective only upon receipt of payment thereof by the undersigned; (FINAL WAIVER)that the final balance due from the Owner is the sum of Dollars ( ) ❑ receipt of which is hereby acknowledged;or ❑ the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which shall become effective upon receipt of such payment. THERFORE,the undersigned waives and releases unto th=Owner of said premises, any and all lien or claim whatsoever on the above-described property and improvements thereo account of LABOR or material or both,furnished by the undersigned thereto, subject to limitations of condition e,po-ssed herein, if any; and further certifies that no other party has any claim or right to a lien on account of any work ,-J a med or material furnished to the undersigned for said project, and within the scope of this affidavit and waiver. /j I Gibraltar Construction Corp By at Title President //A( 11. WITNESS MY HAND AND NOTORIAL S ,� 12 th d y of May, 20 (Notary Public) v. 1979 INO,allos coc1TRACTORSASSOC4ATIO INCO$PO AT(O ���~o,�h BRIAN R. MCBRIDE unsiliNV•tedPsTUOOuci.on►rOfi e•a Res. of Hancock County Raw 1p`f' My Comm. Exp. 11-29-2017 0 I " Commission # 811862 P5 Motor Court (Signature Construction - Gibraltar) January 2011 Application 1 Paid by Carmel Theater Development $ 2,663.15 February 2011 Application 2 Paid by Carmel Theater Development $ 5,414.43 March 2011 Application 3 Paid by Carmel Theater Development $ 6,824.47 April 2011 Application 4 Paid by Carmel Theater Development $ 5,892.25 May 2011 Application 5 Amount to be paid by Carmel Theater Development $ 9,888.20 APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENTG702 PAGE ONE OF 2 PAGES2 TO OWNER CRC at City of Cannel PROJECT: Motor Court APPLICATION NO Invoice II 5-Gibraltor 1 Distribution to: Carmel Indiana 46032 Signature costs OWNER ARCHITECT PERIOD TO: 5/23/2011 X CONTRACTOR FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design Signature Construction Services LLC 720 3rd Avenue S.W. PROJECT NOS: Carmel,Indiana 46032 CONTRACT FOR: CONTRACT DATE: 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 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. I. ORIGINAL CONTRACT SUM $ 25,361.30 2. Net change by Change Orders $ 0.00 CONTRACTOR: 3. CONTRACT SUM TO DATE(Line I ±2) $ 25,361.30 4. TOTAL COMPLETED&STORED TO $ 24,790.25 / / By: / Date: 5/Z 9 )/ 5. RETAINAGE: " omas E. ontz,President a. 0 %of Completed Work $ 0 Subscr bed and om to before me this a, III l day of „(4'/� , 30g •. _ _ (Column D+Eon G703) s LINDA BUCHANAN b. %of Stored Material $ t :'�.. " •Y�•. ,a ��,oraAY• Hancock County (Column F on G703) ::E.. r My Commission Expires Total Retainage(Lines 5a+5b or °! '''l..6;:???`s ust 20,2011 Total in Column l of G703) $ 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT •' -'°'-¢ ';-= - 6. TOTAL EARNED LESS RETAINAGE $ 24,790.25 In accordance with the Contract Documents,based on on-site observations and the data (Line 4 Less Line 5 Total) comprising the application,the Architect certifies to the Owner that to the best of the 7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge,information and belief the Work has progressed as indicated, PAYMENT(Line 6 from prior Certificate) $ 14,902.05 the quality of the Work is in accordance with the Contract Documents,and the Contractor 8. CURRENT PAYMENT DUE $ 9,888.20 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH,INCLUDING RETAINAGE $ 571.05 (Line 3 less Line 6) AMOUNT CERTIFIED $ /567..2V CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation i .i.unt certified differs from the amount applied.Initial all figures on this Total changes approved Application and• the ontinuati Sheet that are changed to conform with the amount certified.) in previous months by Owner ARCHITECT' Total approved this Month By: 'C Date: ,!j/a(/t/ TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein.Issuance,payment and acceptance of payment are without NET CI-IANGES by Change Order $0.00 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 20006-5292 Users may obtain validation of this document by requesting a completed AIA Document D401 -Certification of Document's Authenticity from the Licensee. SIGNATURE CONSTRUCTION LLC 720 3rd Avenue, S. W. Carmel, Indiana 46032 Invoice # 5 - Gibraltor 5/23/11 Motor Court - Gibraltor Carmel, Indiana WORK COMPLETED MATERIALS TOTAL BALANCE ITEM DESCRIPTION OF SCHEDULED FROM PREVIOUS THIS PRESENTLY COMPLETED AND TO Committed NO. WORK VALUE APPLICATIONS PERIOD STORED STORED TO DATE % FINISH Cost General Requirements: Site Supervision 12,680.65 8,113.65 3,995.95 0.00 12,109.60 95% 571.05 12,109.60 Construction Management Fee 12,680.65 6,788.40 5,892.25 0.00 12,680.65 100% 0.00 12,680.65 25,361.30 14,902.05 9,888.20 0.00 24,790.25 98% 571.05 24,790.25 • CONDITIONAL AFFIDAVIT AND WAIVER OF LIEN STATE OF INDIANA COUNTY OF HAMILTON ) Thomas E. Koontz being duly sworn states that he is the President of Signature Construction, LLC having contract to furnish certain materials and /or labor as follows: Construction Management Services for a project known as Motor Court, located at Carmel, Indiana and owned by the Carmel Redevelopment Commission and does state: CONDITIONAL WAIVER: that the balance due from the owner is the sum of nine thousand eight hundred eighty-eight dollars and twenty cents ($9,888.20) the payment of which has been promised as the sole consideration for this Affidavit and Conditional Waiver of Lien which is given to and for said amount, effective upon receipt of such cash payment. THEREFORE, the undersigned waives and releases unto the Owner of said premises any and all line or claim whatsoever on the above-described property and improvements thereon on account of labor or material or both, furnished by the undersigned thereto, and further certifies that no other party has any claim or right to a lien on account of any work perform or material furnished to the undersigned for the said project, and within the scope of this affidavit and waiver. SIGNATURE CONSTRUCTION, LLC j T,Yfoma Koontz, President 1 Subscribed and sworn to before me this: Ay . / '04 Notary Public: °"a P�• LINDA BUCHANAN it nor n • = Hancock County My Commission Expires ...: August 20,2011, _ P5 Motor Court (Smock Fansler) April 2011 Application 1 Paid by Carmel Theater Development $ 55,530.00 May 2011 Application 2 Amount to be paid by Carmel Theater Development $ 36,052.20 AIA Type Document . Application and Certification for Payment Page 1 of 2 TO(OWNER):CARMEL REDEVELOPMENT COMM. PROJECT:MOTOR COURT PAVING APPLICATION NO: 2 DISTRIBUTION 30 W. MAIN ST. 1 e,ED PERIOD TO:5/31/2011 TO: CARMEL, IN 46032 !1 OWNER _ARCHITECT MA ' _ 2011 ARCHITECT'S CONTRACTOR FROM(CONTRACTOR):Smock Fansler Corporation VIA(ARCHITECT): 2910 W.Minnesota Street Per PROJECT NO: Indianapolis, IN 46241 CONTRACT FOR: CONTRACT DATE: CONTRACTOR'S APPLICATION FOR PAYMENT 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 Application is made for Payment, as shown below, in connection with the Contract. Contract Documents,that all amounts have been paid by the Contractor for Work for which previous Continuation Sheet,AIA Type Document is attached. Certificates for Payment were issued and payments received from the owner,and thAtiliipi���ill��� current payment shown herein is now due. �\�..-,, 1.ORIGINAL CONTRACT SUM $ 268,590.00 p y ��, Fi. PUB./C ,•\ AP ,........ i, 2.Net Change by Change Orders $ 0.00 CONTRACTOR: Smock Fansler Corporation .• i • 2910 W.Minnesota Street Indianapolis, IN 46241 _ i AL 3.CONTRACT SUM TO DATE(Line 1 +2) $ 268,590.00 _y.. 4.TOTAL COMPLETED AND STORED TO DATE $ 101,758.00 By IVA. Date: Q / CEO ..1z- '.• 5. RETAINAGE: %of Completed Work $ 10,175.80 State of: IN /°j��i�O���S/TA/TIEII0 .\NOP`\\\\ County of MORGAN b. 0.00%of Stored Material $ 0.00 Subscribed and Sworn to before me this / / Day of int:/, 20 / Total retainage(Line 5a+5b) $ 10,175.80 Notary Public: v614 � L&OG� My Commission Expires: / I ` Q( 76 6.TOTAL EARNED LESS RETAINAGE $ 91,582.20 (Line 4 less Line 5 Total) ARCHITECT'S CERTIFICATE FOR PAYMENT 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT In Accordance with the Contract Documents, based on on-site observations and the data com- (Line 6 from prior Certificate) $ 55,530.00 prising the above application, the Architect certifies to owner that to the best of the Architect's knowledge, information and belief the Work has progressed as indicated,the quality of the work 8.CURRENT PAYMENT DUE $ 36,052.20 is in accordance with the Contract Documents, and the Contractor is entitled to payment of the 9.BALANCE TO FINISH,INCLUDING RETAINAGE AMOUNT CERTIFIED. (Line 3 less Line 6) $ 177,007.80 AMOUNT CERTIFIED $ XC5F.• �v (Attach explanation if amount certified differs from the amount app ied. Initial all figures on this CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Application and on th• .ntinuat,•n Sheet that are changed to conform to the amount certified.)401 Total changes approved in ARCHITECT: previous months by Owner 0.00 0.00 By. .��1r,► Date li Total approved this Month 0.00 0.00 This Certifi..te is •t negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herei . : ance, Payment and acceptance of paym t are without prejudice to any \ I TOTALS 0.00 0.00 rights of the Owner or Contractor under this Contract. NET CHANGES by Change Order 0.00 Director of Redevelopment Cie /,1 �+` 5f3(rf/ /'��60 8e 5' CM - AIA Type Document Application and Certification for Payment Page 2 of 2 TO(OWNER):CARMEL REDEVELOPMENT COMM. PROJECT:MOTOR COURT PAVING APPLICATION NO: 2 DISTRIBUTION 30 W.MAIN ST. TO: CARMEL, IN 46032 PERIOD TO:5/31/2011 _OWNER _ARCHITECT CONTRACTOR FROM(CONTRACTOR):Smock Fansler Corporation VIA(ARCHITECT): ARCHITECT'S 2910 W. Minnesota Street PROJECT NO: Indianapolis, IN 46241 CONTRACT FOR: CONTRACT DATE: SCHEDULE PREVIOUS COMPLETED STORED COMPLETED ITEM DESCRIPTION VALUE APPLICATIONS THIS PERIOD MATERIAL STORED % BALANCE RETAINAGE 1 MOBILIZATION/DEMOBILIZATION 13,200.00 6,600.00 0.00 0.00 6,600.00 50.00 6,600.00 660.00 2 ASPHALT BASE 55,100.00 55,100.00 0.00 0.00 55,100.00 100.00 0.00 5,510.00 3 UNIT PAVERS 200,290.00 0.00 40,058.00 0.00 40,058.00 20.00 160,232.00 4,005.80 REPORT TOTALS $268,590.00 $61,700.00 $40,058.00 $0.00 $101,758.00 37.89 $166,832.00 $10,175.80 AFFIDAVIT AND WAIVER OF LIEN [ ] Final [X] Partial [X] Payment to Follow State of Indiana County of Marion T. M. Fansler, being duly sworn states that he is the CEO of SMOCK FANSLER CORP. having contracted with: Carmel Redevelopment Commission to furnish certain labor, materials, and/or services as follows: Misc. Construction for a project known as: SFC#10-140 Carmel City Ctr. Motor Ct. & Fountains located at Indianapolis, IN and does hereby state on behalf of the aforementioned contractor: (PARTIAL WAIVER)that there is due from the owner the sum of: ($36,052.20) Thirty Six Thousand Fifty Two Dollars and 20/100 [ ] receipt of which is hereby acknowledged; or [X] the payment of which has been promised as the soleconsideration of this Affidavit and Partial Waiver of Lien which is given solely with respect to said amount, and which waiver shall be effective only upon receipt of payment thereof by the undersigned; (FINAL WAIVER)that the final balance due from the owner is the sum of($0.00) [ ] receipt of which is hereby acknowledged; or [ ] the payment of which has been promised as the sole consideration of this Affidavit and Final Waiver of Lien which shall become effective upon receiptof such payment. THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all lien or claim whatsoever on the above-described property and improvements thereon on account of Labor, Materials, and/or Services, furnished by the undersigned thereto, subject to limitations or conditions expressed herein, if any; and further certifies that no other party has any claim or right to a lien on account of any work performed, materials, or services furnished to the undersigned for said project, and within the scope of this affidavit and waiver. •SMOCK FANSLER CORP. By v4, CEO T. M. Fansler \\\\\\\\\\\O \PRYmP�Usiiiiiiii��// WITNESS MY HAND AND NOTARIAL SEAL, this 196 day of May ,2011. • AL Melissa J. Bishop Notary P blic S . \PQ\\o 0 FIN� My commission expires_November 30, 2016_ Residing in Morgan County /4%rnoittiiiiiivio0" P5 Motor Court (Signature Construction - Smock) May 2011 Application 1 Amount to be paid by Carmel Theater Development $ 5,087.90 APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 O PAGE ONE OF 2 PAGES 2 TO OWNER CRC at City of Carmel PROJECT: Motor Court APPLICATION NO Invoice 4 0-Smock I Distribution to: Carmel Indiana 46032 Signature costs OWNER ARCHITECT PERIOD TO: 5/23/201 I X CONTRACTOR FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design Signature Construction Services LLC 720 3rd Avenue S.W. PROJECT NOS: Carmel, Indiana 46032 CONTRACT FOR: CONTRACT DATE: 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 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. I. ORIGINAL CONTRACT SUM $ 26,859.00 2. Net change by Change Orders $ 0.00 CONTRACTOR: 3. CONTRACT SUM TO DATE(Line I±2) $ 26,859.00 4. TOTAL COMPLETED&STORED TO $ 5,087.90 /'Z' Y�� By: ,./ 7 Date: s 5. RETAINAGE: " loma. 'oontz,President a. 0 %of Completed Work $ 0 Subsc bed an. -worn to before me this ....2e( day of "fay t. G.I/ (Column D+Eon G703) / b. %of Stored Material $ 'vo�c LINDA BUCHANAN (Column F on G703) ,or>RY' Hancock County Total Retainage(Lines 5a+5b or see My Commission Expires 2),2011 Total in Column I of G703) $ 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT' 6. TOTAL EARNED LESS RETAINAGE $ 5,087.90 In accordance with the Contract Documents,based on on-site observations and the data (Line 4 Less Line 5 Total) comprising the application,the Architect certifies to the Owner that to the best of the 7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge,information and belief the Work has progressed as indicated, PAYMENT(Line 6 from prior Certificate) $ 0.00 the quality of the Work is in accordance with the Contract Documents,and the Contractor S. CURRENT PAYMENT DUE $ 5,087.90 is entitled to payment of the AMOUNT CERTIFIED. 9. I3ALANCE TO FINISH,INCLUDING RETAINAGE $ 21,771.10 (Line 3 less Line 6) AMOUNT CERTIFIED $ Di7 O CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation if an• nt certified differs from the amount applied.Initial all figures on this Total changes approved Application and onti' Co)tinuati heet that are changed to conform with the amount certified.) in previous months by Owner ARCHITECT: Total approved this Month By: 1Ir `...,- Date: Si g(/(' TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the contractor named herein.Issuance,payment and acceptance of payment are without NET CHANGES by Change Order $0.00 prejudice to any rights of the Owner or Contractor under this Contract. AIA DOCUMENT G702-APPLICATION AND CERTIFICATION FOR PAYMENT.1992 EDITION.AIA .®1992 THE AMERICAN INSTITUTE OF ARCHITECTS,1735 NEW YORK AVE.,N.W.,WASHINGTON,DC 20006-5292 Users may obtain validation of this document by requesting a completed AIA Document D401 -Certification of Document's Authenticity from the Licensee. Director of Redevelopment 4j 6(2$(�5 P SIGNATURE CONSTRUCTION LLC 720 3rd Avenue, S. W. Carmel, Indiana 46032 Invoice # 5 - Smock 5/23/11 Motor Court - Smock Carmel, Indiana WORK COMPLETED MATERIALS TOTAL BALANCE ITEM DESCRIPTION OF SCHEDULED FROM PREVIOUS THIS PRESENTLY COMPLETED AND TO Committed NO. WORK VALUE APPLICATIONS PERIOD STORED STORED TO DATE % FINISH Cost General Requirements: Site Supervision 13,429.50 0.00 0.00 0.00 0.00 0% 13,429.50 0.00 Construction Management Fee 13,429.50 0.00 5,087.90 0.00 5,087.90 38% 8,341.60 5,087.90 26,859.00 0.00 5,087.90 0.00 5,087.90 19% 21,771.10 5,087.90 , CONDITIONAL AFFIDAVIT AND WAIVER OF LIEN STATE OF INDIANA ) COUNTY OF HAMILTON ) Thomas E. Koontz being duly sworn states that he is the President of Signature Construction, LLC having contract to furnish certain materials and /or labor as follows: Construction Management Services for a project known as Motor Court, located at Carmel, Indiana and owned by the Carmel Redevelopment Commission and does state: CONDITIONAL WAIVER: that the balance due from the owner is the sum of five thousand eighty-seven dollars and ninty cents ($5,087.90) the payment of which has been promised as the sole consideration for this Affidavit and Conditional Waiver of Lien which is given to and for said amount, effective upon receipt of such cash payment. THEREFORE, the undersigned waives and releases unto the Owner of said premises any and all line or claim whatsoever on the above-described property and improvements thereon on account of labor or material or both, furnished by the undersigned thereto, and further certifies that no other party has any claim or right to a lien on account of any work perform or material furnished to the undersigned for the said project, and within the scope of this affidavit and waiver. SIGNATURE CONSTRUCTION, LLC. Z________ T omas EO oontz, President Subscribed and sworn to before me this: n1y a f do Notary Public: '' e..-Ld .,,';Y.;..;4;,,, LINDA BUCHANAN . . No.,RY t`: Hancock County s. s,:,: . My Commission Expires .''cE .;#.•' August 20,2011