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HomeMy WebLinkAboutAll Pro Sound - $38,317.50Exhibit 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 Amount to be paid by Village Financial, LLC March work (All Pro Sound) $ 38 317.50 Total Authorized Disbursement $ 38,317.50 MI terms used in these Disbursement Instructions without definition shall have the meanings ascribed thereto in that certain Loan Agreement (PAC Sound Equipment), dated , as of August 31, 2009, by and between Lender and Village Financial, LLC. Dated: 5 S (D CITY OF CARMEL REDEVELOPMENT COMMISSION I�J By Printed Title Les S. Olds Executive Director Draft Sound Equipment All Pro Sound (Mercantile) January 2010 Amount paid by CRC $ 44,707.50 February 2010 Application 2 $ 207,699.30 February amount to be paid from PAC Sound Equipment $ 80,198.10 February amount to be paid from PAC Equipment $ 127,501.20 Amount to be paid by Village Financial $ 207,699.30 March 2010 Amount to be paid by Village Financial $ 38,317.50 APPLICATION AND CERTIFICATE FOR PAYMEN1 AIA DOCUMENT G702 /CMa CONSTRUCTION MANAGER - ADVISER EDITION Page I of 2 TO OWNER: Carmel Redevelopment Comms,st \',ECT: Parcel 7A, Regional Performing One Civic Square, Carmel, LK Q Carmel, IN. (Mail to Shiel Sexton)<'fL \�` USA FROM CONTRACTOR: SJ \' L% '', All Pro Sound s\ ;`�t5 VIA AR . II ECT: CSO Architect Inc. 806 Beverly Parkway \ `� \� \' AD1.RESS: 280 East 96th St. Suite 100 Pensacola, FL 32505 ` \ Indianapolis, IN. 46240 CONTRACT FOR: Production Sou h and C mmuications APPLICATION NO: PERIOD TO: JOB NO: PROJECT #: AGREEMENT CONTRACT DATE: COST CODE: 3/19/2010 S30015 2695 2695 -6020 3/16/2009 27 41 16 Distribution to: x x x x OWNER MANAGER ARCHITECT CONTRACTOR CONTRACTOR'S APPL`P dTION FOR PAYMEN1 Application is made for payment, as shown below, in connection with the Contract. Continuation Sheet, ALA Document G703, is attached. 1. ORIGINAL CONTRACT SUM 2. Net change by Change Orders 3. CONTRACT SUM TO DATE (Line 1 ± 2) 4. TOTAL COMPLETED & STORED TO DATE (Column G on G703) 5. RETAINAGE: a. 10% of Completed Work $ (Column D + E on G703) b. 10% of Stored Material $ (Column F on G703) Total Retainage (Lines 5a + Sb or Total in Column I of 0703) 6. TOTAL EARNED LESS RETAINAGE (Line 4 less 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) $ $1 $ 11,135.00 21,167.70 S 1,581,970.00 51,000.00 1,530,970.00 323,027.00 32,302.70 290,724.30 252,406.80 38,317.50 1,240,245.70 CHANL°E ORDER SUMMARY ADDITIONS DEDUCTIONS Total changes approved in previous months by Owner $51,000.00 Total approved this Month $0 .00 TOTALS $51,000.00 NET CHANGES by Change Order $51,000.00 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 paic 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 CONTRA OR: By: State of: /CA:74e a A Subscribed and sworn to before me this Notary Public: My Commission expires Date: County of: day of M IiON E. JORDAN ` ��� eft NOTARY PUBLIC - STATE OF FLORIDA COMMISSION # DD705193 9/21/2011 "•'' BONDEDTHRUI- 888- NOTARYI In accordance with the Contract Documents, based on on -site observations and the data comprising this application, the Construction Manager and Architect certify to the Owner that to the best of their 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 631(9/Alto SCs�N CERTIFICATE FOR PAYMENT AMOUNT CERTIFIED $ 35,311 er- (Attach explanation if amount certified differs from the amount applied for Initial all figures on this Application and on the Contin Sheet that changed to conform to the amount certified. CO ST • " j ►. • GER: _ _It By: dal: _� Jw - Date: B VI By: Date: 3 L1L 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 under this Contract. O AIA DOCUMENT G702 /CMa APPLICATION AND CERTIFICATION FOR PAYMENT CONSTRUCTION MANAGER - ADVISER EDITION 1992 EDITION AIA® © 1992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1745 NEW YORK AVE., N W , WASHINGTON, DC 20006 -529: Users may obtain validation of this document by requesting of the license a completed AIA Document D401 - Certification of Document's Authenticity G702 /CMa -1992 CONTINUATION SHEET AIA DOCUMENT G703 AlA Document G702, APPLICATION AND CERTIFICATION FOR PAYMENT, containing Contractor's signed certification is attached. In tabulations below, amounts are stated to the nearest dollar. Use Column I on Contracts where variable retainage for line items may apply. ATTLICATION Nb: APPLICATION DATE: PERIOD TO: ARCHITECT'S PROJECT NO: PAGE 2 OF 2 PAGES 3 03/19/10 03/19/10 A B C D E F G H I ITEM NO. DESCRIPTION OF WORK SCHEDULED WORK COMPLETED MATERIALS PRESENTLY STORED (NOT IN D OR E) TOTAL COMPLETED AND STORED TO DATE (D +E +F) % (G ± C) BALANCE TO FINISH (C - G) RETAINAGE (IF VARIABLE RATE) VALUE FROM PREVIOUS APPLICATION (D + E) THIS PERIOD 1 Cable $ 152,365.00 $ - $ - $ 149,325.00 $ 149,325.00 98.00% $ 3,040.00 $ 14,932.50 2 Fabricated Steel $ 23,250.00 $ - $ - $ - $ - 0.00% $ 23,250.00 $ - 3 Racks, Cases, and Carts $ 21,420.00 $ - $ - $ - $ - 0.00% $ 21,420.00 $ - 4 Equipment Electronics $ 830,217.00 $ - $ - $ 62,352.00 $ 62,352.00 7.51% $ 767,865.00 $ 6,235.20 5 Equipment Hardware $ 57,011.00 $ 7,850.00 $ - $ - $ 7,850.00 13.77% $ 49,161.00 $ 785.00 6 Labor $ 341,532.00 $ 11,250.00 $ 42,575.00 $ - $ 53,825.00 15.76% $ 330,282.00 $ 5,382.50 7 Bond $ 49,675.00 $ 49,675.00 $ - $ - $ 49,675.00 100.00% $ - $ 4,967.50 8 Bid Package 6020 General Allowance $ 100,000.00 $ - $ - $ - $ - 0.00% $ 100,000.00 $ - 9 Allowance No. 3 - CAD AS BUILTS $ 5,000.00 $ - $ - $ - $ - 0.00% $ 5,000.00 S - 10 Software Allowance $ 1,500.00 5 - S - S - $ - 0.00% $ 1,500.00 $ - 11 Change Order #1 $ (51,000.00) $ - $ - $ - $ - 100.00% $ (51,000.00) $ - GRAND TOTALS $ 1,530,970.00 $ 68,775.00 $ 42,575.00 $ 211,677.00 $ 323,027.00 18.32% $ 1,250,518.00 $ 32,302.70 AIA DOCUMENT G7tClsecsai 78 To1JtaiINEBalidattoe ofsthis�IIlumeM byas2questing of the license a completed AIA Document D401 - Certification of Document s Authenticlty G703 -1992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVENUE, N W., WASHINGTON, D.0 20006 -5232 • VIDEO • LIGHTING SOLUTIONS Bill Of Sale City of Carmel Redevelopment Commission Parcel 7A, Regional Performing Arts Center Carmel, IN.46032 FOR GOOD CONSIDERATION, and upon payment of Thirty -Eight Thousand Three Hundred Seventeen Dollars and Fifty Cents ($38,317.50), and to extent as billed on Pay Request #3 the undersigned, All Pro Sound Inc., 806 Beverly Parkway, Pensacola, FL. 32505 ( Seller) hereby sells and transfers to City of Carmel Redevelopment Commission( Buyer / Owner ), the following: See Breakdown Attached: Which are stored at: All Pro Sound Inc. Pre - Fabrication Building 602 West Michigan Avenue Pensacola, Florida 32505 Ph. (850)432 -5780 ext. 2075 Fax (850)432 -0844 The Seller warrants it has good title to said property, full authority to sell and transfer same, and that said property is sold free of all liens, claims and encumbrances. Signed under seal this 19th day of March, 2010 All Pro Sound Inc. Signature Chad Edwardso r 1 iI iL . a, Vice Pres �e t _ Signature John Fu Signatu Notary esign Sales 111114k,„ i, f' • ►t � blic j `j,AY PVe�rc CREIGHTON E. JORDAN NOTARY PUBLIC - STATE OF FLORIDA COMMISSION # DD705193 EXPIRES 9/21/2011 BONDEDTHRU 1- 888- NOTARYI DESIGN. BUILD. P ORM. 806 Beverly Parkway • Pensacola, Florida 32505 • Phone 850.432.5780 • Fax 850.469.9780 • www.allprosound.com ACC0 E® CERTIFICATE OF LIABILITY INSURANCE OP ID JR ALLPR -1 PRODUCER Hiles- McLeod Insurance, Inc. PO Box 2747 Pensacola FL 32513 Phone:850- 432 -9912 Fax:850- 432 -3875 DATE (MM/DD/YYYY) 02/04/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED All Pro Sound, Inc. 806 Beverly Parkway Pensacola FL 32505 INSURER A: Everest National Insurance Co. INSURER B: Cincinnati Insurance Company 01209 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR AMYL INSRC TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MMIDD/YYYYL POLICY EXPIRATION DATE (MM/DD/YYYY) LIMITS B X GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY CAP5173383 09/09/08 09/09/11 EACH OCCURRENCE $1,000,000 PREMISES(Ea occurence) $100,000 CLAIMS MADE X OCCUR MED EXP (My one person) $ 5 , 0 0 0 - GEM. 7 PERSONAL 8 ADV INJURY $ 1, 0 0 0, 0 0 0 GENERAL AGGREGATE $2,000,000 AGGREGATE LIMIT APPLIES PER POLICY n JE n LOC PRODUCTS - COMP /OP AGG $ 2 , 0 0 0 , 0 0 0 B AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS CAA5173383 09/09/09 09/09/10 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE UABIUTY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ B EXCESS / UMBRELLA LIABILITY X OCCUR CLAIMSMADE DEDUCTIBLE X RETENTION $ CAP5173383 09/09/09 09/09/10 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 $ $ $ A WORKERS AND EMPLOYERS' ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER (Mandatory If yes, describe SPECIAL COMPENSATION UABIUTY y / N 2700003375091 03/01/09 03/01/10 WCSIAlU- 0rH- TORY OMITS ER E.L EACH ACCIDENT $ 1000000 EXCLUDED? in NH) I under PROVISIONS below EL DISEASE - EA EMPLOYEE $ 1000000 E.L DISEASE - POLICY LIMIT $ 100000 0 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Prject: Parcel 7A Regional Performing Arts Center 777 3rd Ave SW Carmel, IN 46032 Sheil Sexton Co., Inc. is an additional insured with regards to General Liability. CERTIFICATE HOLDER CANCELLATION ©1988 =2009 ACORD CORPOI(ATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION SHEILSE DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Sheil Sexton Co., Inc. REPRESENTATIVES. 902 N Capitol Ave. Indianapolis IN 46204 AUTHO ED REPRESENTATIVE A ( / r.f // V1,0411/ ©1988 =2009 ACORD CORPOI(ATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACRD EVIDENCE OF PROPERTY INSURANCE OP ID: JK DATE (MM /DD/YYYY) 02/04/2010 THIS EVIDENCE OF PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW. THIS EVIDENCE OF PROPERTY INSURANCE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PA/HONE C No, Ext): 850- 432 -9912 AGENCY Hiles- McLeod Insurance, Inc. PO Box 2747 Pensacola, FL 32513 Douglas V. Broxson FAX 850 - 432 -3875 (A/C, No): EMAIL ADDRESS: CODE: 09010 SUB CODE: AGENCY ALLPR -1 CUSTOMER ID IF COMPANY Cincinnati Insurance Company PO Box 145496 Cincinnati, OH 45272 INSURED All Pro Sound, Inc. 806 Beverly Parkway Pensacola, FL 32505 LOAN NUMBER POLICY NUMBER CAP5173383 EFFECTIVE DATE 09/09/08 EXPIRATION DATE 09/09/11 CONTINUED UNTIL 1 TERMINATED IF CHECKED THIS REPLACES PRIOR EVIDENCE DATED: PROPERTY INFORMATION LOCATION/DESCRIPTION 806 Beverly Pkwy Pensacola„ FL 32505 THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EVIDENCE OF PROPERTY INSURANCE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. COVERAGE / PERILS / FORMS AMOUNT OF INSURANCE DEDUCTIBLE Installation /Builders Risk Stored Materials • 1500000 500 REMARKS (Including Special Conditions) Project: Parcel 7A Regional Performing Arts Center 777 3rd Ave SW Carmel, IN 46302 Carmel Redevelopment, One Civic Square, Carmel, IN 46032 is also listed as certificate holder. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE ADDITIONAL INTEREST NAMED BELOW, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. NAME AND ADDRESS Shell Sexton Co, Inc. and Carmel Redevelopment 902 N Capitol Ave Indianapolis, IN 46204 MORTGAGEE LOSS PAYEE ADDITIONAL INSURED X LOAN # AUTHORIZED REPRESENTATIVE ,?� -7/S 1 v---- ACORD 27 (2006/07) © ACORD CORPORATION 1993 -2006. All rights reserved. The ACORD name and logo are registered marks of ACORD U.S. Department of Labor Wage and Hour Division PAYROLL (For Contractor's Optional Use; See Instructions at www.dol.gov /whd /forms /wh347instr.htm) Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. H U.S. \Vagc and Hour Division Rev. Dec. 2008 NAME OF CONTRACTOR OR SUBCONTRACTOR ft1-1, Igo ,ova, I oc . ADDRESS so& TivEALy 7tw . 77N5Aco44, f'• 3Z5o5- OMB No.: 1215 -0149 Expires: 12/31/2011 PAYROLL NO. FOR WEEK ENDING MArem l', 2010 PROJECT AND LOCATION 711 3b CARPfrLI IN . ?ROJJE 2 R CONTRACT NO. erry 9r- ditRt?►t . R V>� WFtt A e 4(1 4 2(095- food® (1) N NO. OF WITHHOLDING N EXEMPTIONS (3) ( (4) DAY AND DATE ( (5) ( (6) ( (7) ( (8) (9) y� 'T' W W T T+F F F 5 5, j j D 0 N q 1 10 1 11 I It 1 1Y 1 14 T FICA T HOLDING T OTHER D TOTAL P HOURS WORKED EACH DAY H GLINT G /rL /ZAATP 0 I � �(�G�i r'iG�aln s 0 6ibo, g gg`�3 ( (o�N3 1 1158L S S3o s g g 8 8 g g 3 3,, oZo, 1q 6 .4E04/0 AMictwoncc,- (Ivy 1-1- S S C C dun s 5�b � �i3 5 5q 3` 9 9� � ��B 3: s S S g g f f ? ? H HD 1'1.4.2. While completion of Form WH -347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection conta ned In 29 C.F.R. §§ 3.3, 5.5(a). The Copeland Act (40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to 'furnish weekly a statement with respect to the wages paid each emp oyes during the preceding week.' U.S. Department of Labor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a signed 'Statement of Compliance' Indicating the the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this Information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing Instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S3502, 200 Constitution Avenue, N.W. Washington, D.C. 20210 (over) Date 3 -3o /fO I, r•e ✓ M • Price.— Ctn. (me f /eie- Signatory Party) (Title) do hereby state: (1) That I pay or supervise the payment of the persons employed by AI-` /,'o s-0LIAM j JC - (Contractor or SuUfcontractor) C1�-Y O r CAr4€L ffettevel-bar PqC-that during the payroll period commencing on the (Building or Work) [� �n ,} , day of /1/101/</A , Zb�a and ending the / / day of M/(r 'th , Z4), all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said on the MA, P Pa So U,N -r-& C C. (Contractor or Subcontractor) from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Start. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. § 3145), and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH ❑ — Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS NAME AND TITLE SIGNATUR MAC6 C014031/egl 07/4 THE WIIELFULfALSIFICATION OF ANY OF THE ABOVE STATEMENTS SUBCONTRAC OR TO CIVIL OR CRIMINAL PROSECUTION SEE SECTION 31 OF THE UNITED STATES CODE UBJECT THE CONTRACTOR OR TLE 18 AND SECTION 231 OF TITLE U.S. Department of Labor Wage and Hour Division NAME OF CONTRACTOR El OR SUBCONTRACTOR PAYROLL (For Contractor's Optional Use; See Instructions at www.dol.gov /whd /forms /wh347instr.htm) Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. H U.S. Wage and Hour Division Rev. Dec. 2008 pct, 7RO ,0cjAP, Its. ADDRESS so& I vEALy ?AV. 70)S4coA4� F'. 3z5' OMB No.: 1215 -0149 Expires: 12/31/2011 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION ZOO CITY CARn *t Re:revat.irmeivro PIe PROJECT OR CONTRACT NO. r -. -.. _ • w I i I I '`�JV 'TVG . 7ti41• s— rrr• -•c L1 /N • - vpw�t.- cm, 7.7 fP°'- (1) NAME AND INDIVIDUAL IDENTIFYING NUMBER (e.g., LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER) OF WORKER NO. OF WITHHOLDING EXEMPTIONS (3) WORK CLASSIFICATION (4) DAY AND DATE (5) TOTAL HOURS (6) RATE OF PAY (7) DEDUCTIONS (9) NET S PAID FOR WEEK Q el 1— W ill- F- , rI 0 o //�� Imo+ �� f O �� GROSS AMOUNT EARNED FICA HOLD IN TAX OTHER TOTAL DEDUCTIONS HOURS WORKED EACH DAY CLOT Gal' 1L4AM Ioo3 i tlee,-irc�6,J ° to 1CP. 0 3 (:)q /1143. 4. Po2,-.1 s 2 g g6 410 2.0•1i jfAn) /00g• 3EAG. (i I Lckore r- n co ° 576 ° �`� 3 34 �y. 4� 98 . (1.1$ 5 g S 8 8 g VD �l.112. 57'ift, pojoUR& Liysr 9 �ijor €r - CO � ° so��' 30 - D . 3��3 q68�'. s 8 8 s s s Vo (IAA ° S 0 // S O ////9 S ° ,//// S ° S While completion of Form WH -347 is optional, it is manda ory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the ' nformation collection conla'ned In 29 C.F.R. §§ 3.3, 5.5(a). The Copeland Act (40 U.S.G. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contrac s to 'furnish weekly a statement with respect to the wages paid each employee during the preceding week? U.S. Department of Labor (DOL) regulations at 29 C.F.Ft § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a signed "Statement of Compliance' Indicating that the payrolls are con-ect and complete and that each laborer or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this Information review the Information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection, Including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection, Including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S3502, 200 Constitution Avenue, N.W. Washington, D.C. 20210 (over) Date 3,30-to f.e a - M. Pr; ce - Cv - /ma_ (f me If Signatory Party) (Title) do hereby state: (1) That I pay or supervise the payment of the persons employed by ,41-1._ 42D sowJ 4 • D (Contractor or Subcontractor) C) yy o r 3r,14 , /QQDIeVPLcOvte,JT IC le-that during the payroll period commencing on the < (Building or Work) % s r 1 ✓ day of %11O.tc'J , ib /v, and ending the t day of Miksai , Z4JO all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said on the MA- Q go So UN -rN C. (Contractor or Subcontractor) from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as. amended (48 Stat. 948, 63 Start. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. § 3145), and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS ❑_ in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH El - Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS NAME AND TITLE THE WILFUL �r- SIGNATUR ►C6 Cbn 11 ALSIFICATION OF ANY OF THE ABOVE STATEMENTS SUBCONTRAC OR TO CIVIL OR CRIMINAL PROSECUTION SEE SECTION 1 31 OF THE UNITED STATES CODE UBJECT THE CONTRACTOR OR ITLE 18 AND SECTION 231 OF TITLE U.S. Department of Labor Wage and Hour Division PAYROLL (For Contractor's Optional Use; See Instructions at www.dol.gov /whd /forms /wh347instr.htm) Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. U.S. Wage and Hour Division Rev. Dec. 2008 NAME OF CONTRACTOR OR SUBCONTRACTOR ADDRESS AIL 7140 ovATP, I /1C . SOG 3JVEtt Y ?w1. 7E0V5AC0441 f'- • 325v,5 OMB No.: 1215 -0149 Expires: 12/31/2011 PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION NIARCti zoo, C f DF t RmiL REDEvEcP-Pr1cNJ 7,4 c 77 3R7> NvEr Srv. [AR1tEL ,day. 4032 PROJECT OR CONTRACT NO. o26.9s_ e2' (1) NAME AND INDIVIDUAL IDENTIFYING NUMBER (e.g., LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER)) OF WORKER NO. OF WITHHOLDING iv EXEMPTIONS (3) WORK CLASSIFICATION (4) DAY AND DATE (5) TOTAL HOURS (6) RATE OF PAY (7) GROSS AMOUNT EARNED 7 (6) DEDUCTIONS (9) NET WAGES PAID FOR WEEK cc MT W T+F G 5 ,pJ FICA WITH- HOLDING TAX OTHER TOTAL DEDUCTIONS O z2'L3 21 ZS u0 Z? �� HOURS WORKED EACH DAY f / / /t t. {., l �r V f tL /', VI f 003 E(edri r✓i o bL16oS • 4i • 603 I1 S31' Sao S .cg S Q 32 so,14 g N and tg; 6 4 I r,�6,Q� - CoMMoN 44' s3o �� 4 547 g ?? 3� Z� s$ g g g 3� Iy. �a 5-rt- f*-Frd [A r eoRAU 4'151 ,, 1 1_4 w e r — CmituNJ ° /3o' 3i u S `' s 8 g g g O //:// S 0 S 0 /://, S 0 S 0 S While completion of Form WH -347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection conta'ned In 29 C.F.R. §§ 3.3, 5.5 a). The Copeland Act (40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each emp oyes during the preceding week." U.S. Department of Labor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or fnanang the construction project, accompanied by a signed "Statement of Compliance" indicating tha the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis -Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this Information review the information to determine that employees have received legally required wages and fringe benefits. Public Burden Statement We estimate that is will take an average of 55 minutes to complete this collection, Including time for reviewing Instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S3502, 200 Constitution Avenue, N.W. Washington, D.C. 20210 (over) Date 3 -3c -/O (f me cif Signatory Party) do hereby state: Wr1Yr?</e1 (Title) (1) That I pay or supervise the payment of the persons employed by AL` /Rc' sotiAM .1 LAIC - (Contractor or Subcontractor) (' Q " °,,' on the p/ (' j'M€[, / IQ VP!- bgftAw% PAeethat during the payroll period commencing on the •et (Building or Work) IA- day of MOLtal Zb /a, and ending the 1.S day of //44-6A , Zo /O all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said AM- P go So UN 1-N c. . (Contractor or Subcontractor) from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Start. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. § 3145), and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That. (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS — in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH ❑ — Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS: NAME AND TITLE AM lJ /7FUL vr�1 /I- SIGNATUR THE WI M.iR�'� i ll ALSIFICATION OF ANY OF THE ABOVE STATEMENTS SUBCONTRAC OR TO CIVIL OR CRIMINAL PROSECUTION SEE SECTION 1 31 OF THE UNITED STATES CODE. UBJECT THE CONTRACTOR OR ITLE 18 AND SECTION 231 OF TITLE