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SIGNATURE CONSTRUCTION, LLC -001859 -4/22/2011 CARMEL REDEVELOPMENT COMMISSION 001859 Signature Construction, LLC Check: 1859 720 3rd Ave., SW Date: 4/22/2011 Carmel, IN 46032 Vendor: SIGNATO1 Prior Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid 3-16 20,901.68 20,901.68 - 0.00 0.00 20,901.68 Application 16 P111 Waterproof 20,901.68 20,901.68 0.00 0.00 20,901.68 APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT 6702 PAGE ONE OF 2 PAGES 2 TO OWNER Carmel Redevelopment Commissio PROJECT: Carmel City Pill Waterproofin APPLICATION NO Invoice# 16 1 Distribution to: One Civic Square Smock Signature costs OWNER Carmel Indiana 46032 ARCHITECT PERIOD TO: 3/25/2011 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,ALA 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. 1. ORIGINAL CONTRACT SUM $ 81,776.00 2. Net change by Change Orders $ 0.00 CONTRACTOR: 3. CONTRACT SUM TO DATE(Line I±2) $ 81,776.00 4. TOTAL COMPLETED&STORED TO $ 51,899.24 r / By: / Date: j .C. // 5. RETAINAGE: /Thotnay Koontz,President 4,-e,�ill /// a. 0 %of Completed Work $ 0 Subscribed d sworn to before me this �.5 day of P t--•• ••'•!!•. • - (Column D+E on G703) 1 .',.. LINDA BUCHANAN b. %of Stored Material $ NOTARYe2 Hancock County (Column F on G703) : sr.SEA,:? My Commission Expires Total Retainage(Lines 5a+5b or l _'f91.;N°• August 20,2011 Total in Column I of G703) $ 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT 6. TOTAL EARNED LESS RETAINAGE $ 51,899.24 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) $ 30,997.56 the quality of the Work is in accordance with the Contract Documents,and the Contractor 8. CURRENT PAYMENT DUE $ 20,901.68 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH,INCLUDING RETAINAGE $ 29,876.76 (Line 3 less Line 6) AMOUNT CERTIFIED $ IDIICI. b CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS I (Attach explanation if amount certified differs from the amount applied.Initial all figures on this Total changes approved Application and ?the__- • uatio'Sheet th • e cl: d to onform wit the amount certified.) in previous months by Owner ARCHITECT: /� �/ 3./1, Total approved this Month By: --i,1or Date: TOTALS $0.00 $0.00 This Certifit to is n t ne.otiable. ' e A OUNT CERTIFIED is payable oVzlii t Contractor na 0 n em.issuanc payment and acceptance 01 payment are witnout 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 /M___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 %/ 4,(6&iy.v SIGNATURE CONSTRUCTION LLC 720 3rd Avenue, S. W. Carmel, Indiana 46032 Invoice # 16 3/25/11 Carmel City P111 Waterproofing-SMOCK Carmel, Indiana Total Work RETAINAGE BALANCE Scheduled _ Completed WITHHELD PREVIOUS TOTAL COMPLETED TO DESCRIPTION Value This period THIS PERIOD APPLICATIONS TO DATE % FINISH General Conditions: SMOCK FANSLER Testing and Inspecting 0.00 0.00 0.00 0.00 0.00 0% 0.00 Project Management 0.00 0.00 0.00 0.00 0.00 0% 0.00 Site Supervision 40,293.00 12,970.93 0.00 0.00 12,970.93 32% 27,322.07 Site Safety Director 0.00 0.00 0.00 0.00 0.00 0% 0.00 Design Drawings 0.00 _ 0.00 0.00 0.00 0.00 0% 0.00 Temporary Electric 0.00 _ 0.00 0.00 0.00 0.00 0% 0.00 Office Supplies 0.00 _ 0.00 0.00 0.00 0.00 0% 0.00 Tools and Equipment 0.00 0.00 0.00 0.00 0.00 0% 0.00 Field Engineering and Surveying 0.00 0.00 0.00 0.00 0.00 0% 0.00 Construction Management Fee 41,483.00 7,930.75 0.00 30,997.56 38,928.31 94% 2,554.69 81,776.00 20,901.68 0.00 30,997.56 51,899.24 63% 29,876.76 . 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 Carmel City Center P111, 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 twenty thousand nine hundred one dollars and sixty-eight cents ($20,901.68) the payment of which has bE 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, finished 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 Th fnas E. opntz, President Subscribed and sworn to before me this: 34-54 Notary Public: :;,,,.,:�•• LINDA BUCHANAN ...AR F= Hancock County s: SEAL ` My Commission Expires a "''.,OF.NOl?'s August 20,2011 .,,"rIRF"6Ylb' i