SIGNATURE CONSTRUCTION, LLC -002481 -11/18/2011 CARMEL REDEVELOPMENT COMMISSION 002481
Signature Construction, LLC Check: 2481
720 3rd Ave., SW Date: 11/18/2011
Carmel, IN 46032 Vendor: SIGNATO1
Prior
Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid
1+ 773.30 773.30 0.00 0.00 773.30
A100 railings
773.30 773.30 0.00 0.00 773.30
•
APPLICATION AND CERTIFICATION FOR PAYMENT AlA DOCUMENT G702 PAGE ONE OF 2 PAGES2
TO OWNER CRC at City of Carmel PROJECT:Parcel 73 APPLICATION NO Invoice#1 Distribution to:
Carmel Indiana 46032 AIOO Railings Signature costs OWNER
ARCI-ILFECT
PERIOD TO: 10/25/201 1 X CONTRACTOR
FROM CONTRACTOR: VIA ARCI-IITECT: 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.
1. ORIGINAL CONTRACT SUM $ 1,546.60
2. Net change by Change Orders $ 0.00 CONTRACTOR:
3. CONTRACT SUM TO DATE(Line 1 t 2) S 1,546.60
4. TOTAL COMPLETED&STORED TO $ 773.30 -
By: / / Date: /b 2. /1
5. RETAINAGE: Thom. F.Koontz,President
a. 0 %of Completed Work $ 0 Su'scribed at%swom to before me this y7S day of /0/ ,aaY.,„
(Column D+Eon G703) /: ;:o.• Vic, LINDA G.BUCHANAN
N TAR"': s Hancock County
b. %of Stored Material $ 9..SEAL,_' My Commission Expires
(Column F on G703) � .",,^F;it..'' August 20,2019
Total Retainage(Lines 5a+5b or
Total in Column I ofG703) $ 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT
6. TOTAL EARNED LESS RETAINAGE $ 773.30 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
8. CURRENT PAYMENT DUE $ 773.30 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH,INCLUDING RETAINAGE $ 773.30 ,.n3 3D
(Line 3 less Line 6) AMOUNT CERTIFIED $
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explana is' i •nouns certified differs from the amount applied.Initial all figures on this
Total changes approved Applicatio and onth,Conti ion Sheet that are changed to conform with the amount certified.) ()(P
in previous months by Owner ARCI{I 1 CT: �
Total approved this Month By: Date: /0/0/
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 wnnout
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 -01992 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 # 1
10/25/11
Parcel 73 A100 Railings
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 773.30 0.00 773.30 0.00 773.30 100% 0.00 773.30
Construction Management Fee 773.30 0.00 0.00 0.00 0.00 0% 773.30 0.00
1,546.60 0.00 773.30 0.00 773.30 50% 773.30 773.30
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
Parcel 73 A100 Railings, 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
seven hundred seventy-three dollars and thirty cents ($773.30) 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
C
(hontz, President
Subscribed and sworn to before me this: J�5-4
Notary Public: (:--q_c..4,6, `yeu-P
as-
'' ;e: LINDA G.BUCHANAN
TARP '": Hancock County
N. SEAL . :
s My Commission Expires
`, 5, ,:
August20,2019
Prescribed by State Board of Accounts City Form No.201(Rev.1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Si9n Ure (oh0fr4 1i On Servite3 Purchase Order No.
l20 Ti 4e., 51/ Terms
Cc,r it e\) �. A/ 14032_ Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
P�3 A100 r&iiihys 773, 30
.70
773
Total
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct a • . j.u. -_ ame in accordance
with IC 5-11-10-1.6.
II —I4 , 20f1 - t�
reasurer
VOUCHER NO. WARRANT NO.
11 ALLOWED 20
Si9hd ire Coh54Wf idh Services
IN SUM OF $
X 20 Ord Ave 5
Ctrme,1` N Lf 032
$ 773, 30
ON ACCOUNT OF APPROPRIATION FOR
102_ /L.1L1fl87.3
Board Members
Po#or INVOICE NO. ACCT#/TITLE AMOUNT
DEPT.# I hereby certify that the attached invoice(s), or
C10- 1 `I60873 773. 36 bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
li-3-20
ignature
Executive Director
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund Carmel Redevelopment Commission