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HomeMy WebLinkAboutSIGNATURE CONSTRUCTION, LLC -002498 -12/5/2011 Transmittal Sheet Page 1 ' Carmel Redevelopment Comm Signature Construction, LLC Check: 2498 720 3rd Ave., SW Date: 12/5/2011 Carmel, IN 46032 Vendor: SIGNAT01 Prior Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid 1- 9,922.14 9,922.14 0.00 0.00 9,922.14 pp 1 on Motor Court P112 1-Sign 3,846.21 3,846.21 0.00 0.00 3,846.21 Sign Craft 3*2 9,916.15 9,916.15 0.00 0.00 9,916.15 Site Amenities-LaFever 3- 134.92 134.92 0.00 0.00 134.92 Site amenities-Smock 6- 864.00 864.00 0.00 0.00 864.00 App 6 on Hanover Square Founta 24,683.42 24,683.42 0.00 0.00 24,683.42 APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENTG702 PAGE ONE OF 2 PAGES2 TO OWNER CRC at City of Carmel PROJECT: Hanover Square Fountain APPLICATION NO Invoice#6 1 Distribution to: Carmel Indiana 46032 Signature costs OWNER ARCHITECT PERIOD TO: 10/25/2011 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,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 $ 33,150.00 2. Net change by Change Orders $ 0.00 CONTRACTOR: 3. CONTRACT SUM TO DATE(Line 1 ±2) $ 33,150.00 4. TOTAL COMPLETED&STORED TO $ 33,071.50 , / By �: / Date: /0 Z� 5. RETAINAGE: Thomas .Koontz,President a. 0 %of Completed Work $ 0 S ',scribed a,s sworn to before me this a day of /07/ ' • (Column D+E on G703) : o. Y^ug. LINDA G.BUCHANAN Hancock County b. %of Stored Material $ --:NOTARY::s (Column F on G703) . ,, ,s�^�.?;= My Commission Expires ( ) ,,ice Total Retainage(Lines 5a+5b or Au!USt20 2019 Total inColumnlofG703) $ 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT 6. TOTAL EARNED LESS RETAINAGE $ 33,071.50 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) $ 32,207.50 the quality of the Work is in accordance with the Contract Documents,and the Contractor 8. CURRENT PAYMENT DUE $ 864.00 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH,INCLUDING RETAINAGE $ 78.50 (Line 3 less Line 6) AMOUNT CERTIFIED $ ft'{,°° CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation if amount certified differs from the amount applied.Initial all figures oin this Total changes approved Application onthe Continuation Sheet that are changed to conform with the amount certified.) in previous months by Owner ARCHITE Total approved this Month By: Date: 10/S f((TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the 091/ 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. SIGNATURE CONSTRUCTION LLC 720 3rd Avenue, S. W. Carmel, Indiana 46032 Invoice # 6 10/25/11 Hanover Square Fountain 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 16,575.00 16,575.00 0.00 0.00 16,575.00 100% 0.00 16,575.00 Construction Management Fee 16,575.00 15,632.50 864.00 0.00 16,496.50 100% 78.50 16,496.50 33,150.00 32,207.50 864.00 0.00 33,071.50 100% 78.50 33,071.50 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 I or labor as follows: Construction Management Services for a project known as Hanover Square Fountain, 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 eight hundred sixty-four dollars ($864.00) 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 Thir as E. ntz, President Sub ribed and sworn to before me this: /0%51 Notary Public: o. •''"•F ., LINDA G.BUCHANAN . ?'rvornar = Hancock County My Commission Expires August 20,2019 i` APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENTG702 PAGE ONE OF 2 PAGES2 TO OWNER CRC at City of Carmel PROJECT: PI 12 Motor Court APPLICATION NO Invoice#1 Distribution to: Carmel Indiana 46032 Veneer Signature costs OWNER ARCH ITECF PERIOD TO: 10/25/2011 X CONTRACTOR FROM CONTRACTOR: VIA ARCHITECT: Pcdcor 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 $ 21,000.00 2. Net change by Change Orders $ 0.00 CONTRACTOR: 3. CONTRACT SUM TO DATE(Line 1 +2) $ 21,000.00 4. TOTAL COMPLETED&STORED TO $ 9,922.14 By: // Date: JO A$ 1/ 5. RETAINAGE: "Thom _ oontz,President / a. 0 %of Completed Work $ 0 Su scribed an sworn to before me this s -- day of A 4..-_W (Column D+E on G703) ,o;;YPy''-" LINDA G.BUCHANAN b. %of Stored Material $ ' •NOTARY: z Hancock County (Column F on G703) .SEAL. My Commission Expires v'fet".o,�,: Total Retainage(Lines 5a+5b or Auiust 20 2019 Total in Column l of G703) $ 0.00 ARCHITECT'S CERTIFICATE F•'--`'`- '-► •• i- 6. TOTAL EARNED LESS RETAINAGE $ 9,922.14 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 $ 9,922.14 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH,INCLUDING RETAINAGE $ 11,077.86 (Line 3 less Line 6) AMOUNT CERTIFIED $ s t d••i l CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation if amount certified differs from the amount applied.Initial all figures on this OI / Total changes approved Application a . o he Continuation Sheet that are changed to conform with the amount certified.) P( (� in previous months by Owner ARCI iITEC : !/0 Total approved this Month By: �✓" Date: loiri 1/ TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the contractor nameci herein. Issuance,payment ano acceptance of payment are wimout 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. $. • - 4 SIGNATURE CONSTRUCTION LLC 720 3rd Avenue, S. W. Carmel, Indiana 46032 Invoice # 1 10/25/11 P112 Motor Court Veneer - 12036 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 10,500.00 0.00 7,719.64 0.00 7,719.64 74% 2,780.36 7,719.64 Construction Management Fee 10,500.00 0.00 2,202.50 0.00 2,202.50 21% 8,297.50 2,202.50 21,000.00 0.00 9,922.14 0.00 9,922.14 47% 11,077.86 9,922.14 • 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 P112 Motor Court Veneer, 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 nine hundred twenty-two dollars and fourteen cents ($9,922.14) 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 f' Thom_.. Koontz, President Subscribed and sworn to before me this: 41/5-4 Notary Public: % -4 _14-#--` LINDA G.BUCHANAN =' TARS Hancock County N• SEAL..2, My Commission Expires "�'�, �O,`' August 20,2019 APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENTG702 PAGE ONE OF 2 PAGES2 TO OWNER CRC at City of Carmel PROJECT: Site Amenities APPLICATION NO Invoice S I Distribution to: Carmel Indiana 46032 SignCraft Signature costs OWNER ARCHITECT PERIOD TO: 10/25/2011 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 $ 7,814.00 2. Net change by Change Orders $ 0.00 CONTRACTOR: 3. CONTRACT SUM TO DATE(Line 1 ±2) $ 7,814.00 4. TOTAL COMPLETED&STORED TO $ 3,846.21 / ,. By: f Date: /O 2 S //t 5. RETAINAGE: " -Lomas F '”ntz,President a. 0 %of Completed Work $ 0 Subscribed and sN ern to before me this .„23--- .y of /Q/ tj (Column D+E on G703) \ ,ros'""' LINDA G.BUCHANAN b. %of Stored Material $ _ .NOTARY s Hancock County (Column F on G703) .,.•SEAL../ My Commission Expires Total Retainage(Lines Sa+Sb or • ...g?;"• August 20,2019 Total in Column I of G703) $ 0.00 ARCHITECT'S CERTIFICATE FOR P ,',. N 6. TOTAL EARNED LESS RETAINAGE $ 3,846.21 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 $ 3,846.21 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH,INCLUDING RETAINAGE $ 3,967.79 (Line 3 less Line 6) AMOUNT CERTIFIED $ `+104 CI-IANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation i nount certified differs from the amount applied.Initial all figures on this Total changes approved Application and nthe ontint Sheet that are changed to conform with the amount certified.) in previous months by Owner ARCHITECT' Total approved this Month By: Date: 1 Oft f 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. . � ' 4 . • (.' ' . *�. ° SIGNATURE CONSTRUCTION LLC 720 3rd Avenue, S. W. Carmel, Indiana 46032 Invoice # 1 10/25/11 P112 Site Amenities - Signcraft 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 3,907.00 0.00 3,846.21 0.00 3,846.21 98% 60.79 3,846.21 Construction Management Fee 3,907.00 0.00 0.00 0.00 0.00 0% 3,907.00 0.00 7,814.00 0.00 3,846.21 0.00 3,846.21 49% 3,967.79 3,846.21 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 Site Amenities, 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 three thousand eight hundred forty-six dollars and twenty-one cents ($3,846.21) 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 Tho s E. ontz, President /' Subscribed and sworn to before me this: Notary Public: "•< LINDA G.BUCHANAN Hancock County . s r My Commission Expires 4 :5;;." August 20,2019 f APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE ONE OF 2 PAGES TO OWNER CRC at City of Carmel PROJECT: Site Amenities APPLICATION NO Invoice#3 Distribution to: Carmel Indiana 46032 Smock Signature costs OWNER ARCHITECT PERIOD TO: 10/25/2011 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,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 $ 5,198.50 2. Net change by Change Orders $ 0.00 CONTRACTOR: 3. CONTRACT SUM TO DATE(Line 1 ±2) $ 5,198.50 4. TOTAL COMPLETED&STORED TO $ 5,116.10 By: f ■ Date: ///p S--/j/ 5. RETAINAGE: Thoma - Koontz,President a. 0 %of Completed Work $ 0 S scribed an sworn to before me this day of P� LINDA G.BUCHANAN y . ... •`M (Column D+E on G703) . `?:NOTARY. = Hancock County b. %of Stored Material $ •.SEAL.., My Commission Expires (Column I,on G703) o>�6vi4August 20 2019 •Total Retainage(Lines 5a+5b or ---. Total in Column I of G703) $ 0.00 ARCHITECT'S CERTIFICATE F•R PAYMENT 6. TOTAL EARNED LESS RETAINAGE $ 5,1 16.10 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) $ 4,981.18 the quality of the Work is in accordance with the Contract Documents,and the Contractor 8. CURRENT PAYMENT DUE $ 134.92 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH,INCLUDING RETAINAGE $ 82.40 (Line 3 less Line 6) AMOUNT CERTIFIED $ '3 '' CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanati if mount certified differs from the amount applied.Initial all figures on this Oti Total changes approved Application an ont Continuation Sheet that are changed to conform with the amount certified.) in previous months by Owner ARCI IITEC Total approved this Month By: _ Date: /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 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. SIGNATURE CONSTRUCTION LLC 720 3rd Avenue, S. W. Carmel, Indiana 46032 Invoice # 3 10/25/11 P112 Site Amenities - Smock Carmel, Indiana WORK COMPLETED 1 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 2,599.25 2,516.85 0.00 0.00 2,516.85 97% 82.40 2,516.85 Construction Management Fee 2,599.25 2,464.33 134.92 0.00 2,599.25 100% 0.00 2,599.25 5,198.50 4,981.18 134.92 0.00 5,116.10 98% 82.40 5,116.10 A3:1Kat _ , 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 I or labor as follows: Construction Management Services for a project known as Site Amenities, 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 one hundred thirty-four dollars and ninty-two cents ($134.92) 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 — f T omas ' oontz, President Su scribed and sworn to before me this: /0/, . 5-4 Notary Public: ; Y Pia•. LINDA G.BUCHANAN Hancock County My Commission Expires :s= August 20,2019 t APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE ONE OF 2 PAGES 2 TO OWNER CRC at City of Carmel PROJECT: Site Amenities APPLICATION NO Invoice#3 Distribution to: Carmel Indiana 46032 Lafever Signature costs OWNER ARCHITECT PERIOD TO: 10/25/2011 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,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 $ 28,290.00 2. Net change by Change Orders $ 0.00 CONTRACTOR: 3. CONTRACT SUM TO DATE(Line I±2) $ 28,290.00 4. TOTAL COMPLETED&STORED TO $ 24,942.48 �....— By: / Date: /13/4.g i/' 5. RETAINAGE: Thom. ,/oontz,President a. 0 %of Completed Work $ 0 S,bscribed an worn to before me this (2- day of /0 bI - - (Column D+E on G703) Y LINDA G.BUCHANAN Hancock County b. %of Stored Material $ _ 'NARY• a (Column F on G703) , Nr sEA .s, My Commission Expires -+.0 ,�P. Total Retainage(Lines 5a+5b or August 20,2019 Total in Column I of G703) $ 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT"°'" 6. TOTAL EARNED LESS RETAINAGE $ 24,942.48 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) $ 15,026.33 the quality of the Work is in accordance with the Contract Documents,and the Contractor 8. CURRENT PAYMENT DUE $ 9,916.15 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH,INCLUDING RETAINAGE $ 3,347.53 IU (Line 3 less Line 6) AMOUNT CERTIFIED $ CHI/ i.C. CkCHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanatio amount certified differs from the amount applied.Initial all figures on this Total changes approved Application an nthe Conti Lion Sheet that are changed to conform with the amount certified.) in previous months by Owner ARCHITEC nthe Total approved this Month By: Date: /0/J/h/ TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Lontractor 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. I.C;) Vs, • SIGNATURE CONSTRUCTION LLC 720 3rd Avenue, S. W. Carmel, Indiana 46032 Invoice # 3 10/25/11 P112 Site Amenities - Lafever 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 13,145.00 13,145.00 0.00 0.00 13,145.00 100% 0.00 13,145.00 Meetings 1,000.00 0.00 0.00 0.00 0.00 0% 1,000.00 0.00 Construction Management Fee 14,145.00 1,881.33 9,916.15 0.00 11,797.48 83% 2,347.53 11,797.48 28,290.00 15,026.33 9,916.15 0.00 24,942.48 88% 3,347.53 24,942.48 • 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 Site Amenities, 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 nine hundred sixteen dollars and fifteen cents ($9,916.15) 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 Tho as E. ontz, President Su scribed and sworn to before me this: /D/ S/// Notary Public: " P '"'' LINDA G.BUCHANAN ."°TAI v*::: Hancock County s.•sEAL My Commission Expires August 20,2019 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 S 19 ti&* ate Cens4-ru c ion Ser vi 05 Purchase Order No. 12O ✓2-1 Ave. ) 51W Terms C Ar TINA) I I 1 .■ 1 b32._. Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 10-25—q C 1 dthOite r 5j.0-e htnhj 8 61.k.' t0-25-II 1 r112- 'hid- Court Vcne.r gi122.VA 10-25_11 I pill 54 e Amen di es (5i9/)heir-F) 184 2I I0-25-1( 3 P)I1 if Amenities (5, 0k) • !3t1 92 10-25-(( 3 PIII Side blend ie5 (Lek Fero-) 1/916. 15 - t7: kA "C) ..s Qs Total 24J 683."12;:, :' I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct .•- %IR e: e in accordance with IC 5-11-10-1.6. .-- I-2- -2- , 201 f . ..<:•0! `" o °n -Gler-14-Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 S i 9iheU!"e Cons-f tiG/ion Semites IN SUM OF $ 720 .3 "—d Ave. , S.W, .. C I 't0032 $ 2 6/5 Lt2 ON ACCOUNT OF APPROPRIATION FOR 9u21 1.14+ Board Members PO#or INVOICE NO. ACCT#!TITLE AMOUNT hereby certify invoice(s),DEPT.# I hereb certif that the attached invoices , or 902 6 ilttb 0(05 864, 0b bill(s) is (are) true and correct and that the 90) I 1146005 t(ILL t`f materials or services itemized thereon for °102 d Ogas 3j jw.2I which charge is made were ordered and en, 3 60805 /311, 12 received except -801- 3 60 03 q 9105 II- 3— 20/( Signature Executive Director Title Cost distribution ledger classification if claim paid motor vehicle highway fund Carmel Redevelopment Commission