Loading...
HomeMy WebLinkAboutGIBRALTAR CONSTRUCTION CORP -002577 -12/23/2011 CARMEL REDEVELOPMENT COMMISSION 002577 z Gibraltar Construction Corp Check: 2577 2932 N. Webster Ave. Date: 12/23/2011 Indianapolis, IN 46219 Vendor: GIBR1 Prior Invoice P.O. Num. invoice Amt Balance Retention Discount Amt. Paid 4-8 6,730.00 6,730.00 0.00 0.00 6,730.00 App 8 on Lofts Streetscape P47 4-9 5,220.00 5,220.00 • 0.00 0.00 5,220.00 ' App 9 on P47 Lofts Streetscape " . 11,950.00 1,1,950:00, , 0`.00';' 0.00. ;11;950.00 `V ATY AIA \ Document G7O2ICMaTM - 1992 rt‘-' _...„ . \ (A)Application and Certificate for Payment Construction Manager-Adviser Edition TO OWNER: PROJECT: APPLICATION NO: Distribution to: City of Carmel Carmel Lofts Streetscape-Parcel 47 L�, 8 One Civic Square PERIOD TO: 10/31/11 OWNER ❑ Carmel, IN 46032 CONSTRUCTION MANAGER ❑ FROM CONTRACTOR: Gibraltar Construction Corp VIA CONSTRUCTION MANAGER: CONTRACT DATE: 2/4/11 ARCHITECT ❑ 2932 N.Webster Ave. PROJECT NOS: / / CONTRACTOR ❑ Indianapolis,IN 46219 VIA ARCHITECT: FIELD ❑ CSO Architects, Inc. CONTRACT FOR: Parcel 47-Carmel Lofts Streetscape ❑ CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor -reifies 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 cols Application for Payment has been completed in accordance with the Continuation Sheet,AIA Document G703,is attached. Contract Documents, that:,11 .linounts have been paid by the Contractor for Work for which previous Certificates for Payment; ell- issued and payments received from the Owner, and that current 1.ORIGINAL CONTRACT SUM $ 1,373,700.00 payment shown herein i•,/�sw one. 2. Net change by Change Orders $ 246,999.00 CONTRACTOR: Gibra.'- 'C.nstruction Corp 3.CONTRACT SUM TO DATE(Line 1 ±2) $ 1,620,699.00 By: It Date: "--"/Y.'***ll 4.TOTAL COMPLETED&STORED TO DATE(Column G on G703) $ 1,610,589.00 State of: .014/2 - 1'r MCBRDE 5.RETAINAGE: County of: �f �i .. ��, .. �0;,� County a. %.of Completed Work Subscribe and ., , .�- . F r�1 (Column D+Eon G703) $ 70,435.00 me this ,j i ! y of/1 ���" �11 M'I ' L-'l'w 1!1-29-2017 b. %of Stored Material Not. • - / in ?�P U:2771.-'7-:•0•71 ' i 1862 (Column F on G703) $ • My Commi•Fon expires://.---.2-e7.--/-7 Total Retainage(Lines 5a+5b or Total in Column I of G703). $ CERTIFICATE FOR PAYMENT 1,540,154.00 In accordance with the Contract Documents, based on on-site observations and the data comprising 6.TOTAL EARNED LESS RETAINAGE $ 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 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT $ 1,533,424.00 accordance with the Contract Documents,and the Contractor is entitled to payment of the AMOUNT (Line 6 from prior Certificate) CERTIFIED. 8.CURRENT PAYMENT DUE $ 6,730.00 AMOUNT CERTIFIED $40, 30.QA 9.BALANCE TO FINISH,INCLUDING RETAINAGE (Attach explanation if amount certified differs from the amount applied.Initial all figures on this Application and on the Continuation Sheet that are changed to conform with the amount certi G-i (Line 3 less Line 6) $ 80,545.00 CONSTRUCTION MA ER: By: Date: CHANGE ORDER SUMMARY ADDITIONS, DEDUCTIONS ARCHITE •Ar.` i.Total changes approved in previous months by Owner $ $ By: � Date: /2/(3/g Total approved this Month $ $ This Certificate is not negotiable. The AMOUNT CER III LED is-payable only to the Contractor TOTALS $ $ named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of NET CHANGES by Change Order $ the Owner or Contractor under this Contract. CAUTION:You should sign an original AIA Contract Document,on which this text appears in RED. An original assures that changes will not be obscured. ALA Document G702/CMar"-1992.Copyright ©1992 by The American Institute of Architects.All rights reserved.WARNING:This AIA® Document is protected by U.S.Copyright Law and International Treaties. 1/460 S41 7 CONTINUATION SHEET Page 2 of 4 . APPLICATION NO. : 8 APPLICATION AND CERTIFICATE FOR PAYMENT, containing Contractor's signed Certification, is APPLICATION DATE: 10/31/2011 attached. In tabulations below, amounts are stated to the nearest dollar. Use Column I on Contracts where PERIOD TO: 10/31/2011 variable retainage for line items may apply. ARCHITECT'S PROJECT NO. : A B C D E F G H I WORK COMPLETED MATERIALS TOTAL ITEM PRESENTLY COMPLETED AND % BALANCE TO RETAINAGE DESCRIPTION OF WORK SCHEDULED VALUE FROM PREVIOUS FINISH (IF VARIABLE NO. APPLICATION THIS PERIOD STORED(NOT IN STORED TO DATE (G/C) (D+E) DORE) (D+E+F) (C G) RATE) 1 Allowance No. 1 -Base Bid Contingency $5,000.00 $5,000.00 $5,000.00 100% - _ 2 Allowance No. 2-Winter Conditions $30,000.00 $30,000.00 $30,000.00 100% - 3 Allowance No. 3-Alternate 1 Contingency $5,000.00 $5,000.00 $5,000.00 100% - 4 Allowance No. 4-Alternate 2 Contingency $5,000.00 $5,000.00 $5,000.00 100% - _ 5 Allowance No. 5-Alternate 3 Contingency $5,000.00 $5,000.00 $5,000.00 100% - 6 Allowance No. 6-Alternate 4 Contingency $5,000.00 $5,000.00 $5,000.00 100% - 7 Bond $18,500.00 $18,500.00 $18,500.00 100% - 8 General Conditions $86,000.00 $86,000.00 $86,000.00 100% - 9 Site Clearing/Selective Site Demo $29,200.00 $29,200.00 $29,200.00 100% - 10 Earthwork $114,500.00 $114,500.00 $114,500.00 100% - 70,435.00 11 Stuctural Soil $7,800.00 $7,800.00 $7,800.00 100% - 12 Erosion/Sedimentation Control $500.00 $500.00 $500.00 100% - 13 Water Distribution $48,200.00 $48,200.00 $48,200.00 100% - 14 Storm Drainage $139,700.00 $139,700.00 $139,700.00 100% - 15 Asphalt Paving $16,900.00 $16,900.00 $16,900.00 100% - 16 Cast-in-Place Concrete-Mt'l $7,750.00 $7,750.00 $7,750.00 100% - 17 Cast-in-Place Concrete-Labor $6,350.00 $6,350.00 $6,350.00 100% - 18 Trench Drains-Mt'l $7,500.00 $7,500.00 $7,500.00 100% - 19 Trench Drains- Labor $2,300.00 $2,300.00 $2,300.00 100% - 20 Concrete Paving $156,454.00 $156,454.00 $156,454.00 100% - 21 Concrete Footing and Walls $43,900.00 $43,900.00, $43,900.00 100% - 22 Paving Joint Sealants $3,700.00 $3,700.00 $3,700.00 100% - 23 Unit Paver-Concrete $79,000.00 $79,000.00 $79,000.00 100% - 24 Permeable Unit Paving System - Concrete $65,000.00 $65,000.00 $65,000.00 100% - 25 Segmental Rataining Wall $25,000.00 $25,000.00 $25,000.00 100% - CONTINUATION SHEET Page 3 of 4 APPLICATION NO. : 8 APPLICATION AND CERTIFICATE FOR PAYMENT, containing Contractor's signed Certification, is APPLICATION DATE: 10!31/2011 attached. In tabulations below, amounts are stated to the nearest dollar. Use Column I on Contracts where variable retainage for line items may apply. PERIOD TO: 10/31/2011 ARCHITECT'S PROJECT NO. : A B C D E F G H I WORK COMPLETED MATERIALS ITEM TOTAL COMPLETED BALANCE TO DESCRIPTION OF WORK SCHEDULEDVALUE FROM PREVIOUS PRESENTLY AND STORED TO % FINISH RETAINAGE NO. t APPLICATION THIS PERIOD STORED(NOT IN DATE(D+E+F) (G/C) (C G) (IF VARIABLE RATE) (D+E) D OR E) 26 Bollards- Mt'l $5,050.00 $5,050.00 $5,050.00 100% - 27 Bollards- Labor $800.00 $800.00 $800.00 100% - 28 Masonry $9,000.00 $9,000.00 $9,000.00 100% - 29 Brick Masonry $7,000.00 $7,000.00 $7,000.00 100% - 30 Cast Stone $7,000.00 $7,000.00 $7,000.00 100% - 31 Pipe&Tube Railings-Steel $49,500.00 $49,500.00 $49,500.00 100% - 32 Water Repellants $700.00 $700.00 $700.00 100% - 33 Thermoplastic Membrane Waterproofing $76,000.00 $72,280.00 $72,280.00 95% 3,720 34 High Performance Pond Coatings- Mt'l $1,000.00 $0.00 0% 1,000 35 High Performance Pond Coatings- Labor $1,000.00 $0.00 0% 1,000 36 Post& Panel Signs $5,300 5,300 $5,300.00 100% - 37 Fountain Structure- Mt'l $28,100 28,100 $28,100.00 100% - 38 Fountain Structure- Labor $800 760 40 $800.00 100% - 39 Fountain Plumbing - Mt'l $12,000 12,000 $12,000.00 100% - 40 Fountain Plumbing- Labor $3,000 3,000 $3,000.00 100% - 41 Electrical $223,000 211,920 6,690 $218,610.00 98%, 4,390 42 Exterior Plants $8,200 8,200 $8,200.00 100% - 43 Tree Gates- Mt'l $9,846 9,846 $9,846.00 100% - 44 Tree Gates-Labor $1,400 1,400 $1,400.00 100% - 45 Bike Racks- Mt'l $900 900 900 100% - 46 Bike Racks- Labor $600_ 600 600 100% - 47 Planters-Mt'l $9,500 9,500 9,500 100% - 48 Planters- Labor $750 750 750 100% .. 49 Change Order#1 $35,000 35,000 35,000 100% - 50 Change Order#2 $116,941 116,941 116,941 100% - 1 CONTINUATION SHEET Page4of4 APPLICATION NO. : 8 APPLICATION AND CERTIFICATE FOR PAYMENT, containing Contractor's signed Certification, is APPLICATION DATE: 10/31/2011 attached. In tabulations below, amounts are stated to the nearest dollar. Use Column I on Contracts PERIOD TO: 10/31/2011 where variable retainage for line items may apply. ARCHITECT'S PROJECT NO. : A B C D E F G H I WORK COMPLETED MATERIALS TOTAL ITEM SCHEDULED BALANCE TO NO. DESCRIPTION OF WORK VALUE FROM PREVIOUS PRESENTLY COMPLETED AND % FINISH RETAINAGE APPLICATION THIS PERIOD STORED(NOT IN STORED TO DATE (G/C) (IF VARIABLE RATE) (D+E) DORE) (D+E+F) (C G) 51 Change Order#3 -$20,000 (20,000) (20,000) 100% - 52 Change Order#4 $32,386 32,386 32,386 100% - 53 Change Order#5 $59,972 59,972 59,972 100% - 54 Change Order#6 $0 - 55 Change Order#7 $8,960 8,960 8,960 100% - 56 Change Order#8 $6,571 6,571 6,571 100% - 57 Change Order#9 -$10,600 (10,600) (10,600) 100% - 58 Change Order#10 $17,769 17,769 17,769 100% - 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 $1,620,699 $1,603,859 $6,730 $0 $1,610,589 99% $10,110 $70,435 ISA Form # 1-402 x : 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 Arts District Lofts Streetscape, Parcel 47 and owned by City of Carmel, Indiana. and does hereby further state on behalf of the aforementioned contractor: -- (PARTIAL WAIVER)that there is due from the Owner the sum of - - - Six Thousand Seven Hundred Thirty and No/100 Dollars ($6,730.00) ❑ 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_ •wner 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,i .xp 1essed herein, if any; and further certifies that no other party has any claim or right to a lien on account of any work i -rf' med or material furnished to the undersigned for said project, and within the scope of this affidavit and waiver.i J Gibraltar Construction Corp By Title President WITNESS MY HAND AND NOTORIAL SE/4fr h d=;I of October, 2011. (Notary Public) >",` ' ,, SRIAN R. MCBRIDE isrs 4■401ANA SuaCONTAACTOAS ASSOCIATION tNCOA90 ifo a Res. of Hancock County um/ton:y.46a Reo.oducnon PrdN,bitod ST AL * sew „�x My Comm. E'4_o I 1-29-201 - <i n; tiP - . .� 671862 . ..........„ . ` I LI,A0 / Document G7O2ICMa TM ® 1992 Application and Certificate for Payment Construction Manager-Adviser Edition N TO OWNER: Cit PROJECT: APPLICATION NO: D'. bution to: y of Carmel Carmel Lofts Streetscape-Parcel 47 N-9 One Civic Square PERIOD TO: 11/30/11 OW ER ❑ Carmel,IN 46032 CONSTRUCTION MANAGL• ❑ FROM CONTRACTOR: Gibraltar Construction Corp VIA CONSTRUCTION MANAGER: CONTRACT DATE: 2/4/11 ARCHITEC ❑ 2932 N.Webster Ave. PROJECT NOS: / / CONTRACTOR ❑ Indianapolis,IN 46219 VIA ARCHITECT: FIELD I CSO Architects, Inc. CONTRACT FOR: Parcel 47-Carmel Lofts Streetscape I' CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certi s that to the best of the Contractor's knowledge, information al,. Application is made for payment,as shown below, in connection with the Contract. belief the Work covered by th, •..plication for Payment has been completed in accordance with th• Contract Documents, that all .d, o is have been paid by the Contractor for Work for which previou. Continuation Sheet,AIA Document G703,is attached. 11' Certificates for Payment w•�. i ued and payments received from the Owner, and that current 1.ORIGINAL CONTRACT SUM $ 1.373.700.00 payment shown herein is no�f e If 2. Net change by Change Orders $ 246,999.00 CONTRACTOR: Gibralta�I •n=4 ruction Corp 3.CONTRACT SUM TO DATE(Line 1 ±2) ' $ 1,620,699.00 By: ,;tom_ Date: � 1.- 4/ 4.TOTAL COMPLETED&STORED TO DATE(Column G on G703) $ 1,615,809.00 State of:i3O,7. /I/i ft 5.RETAINAGE: County of: /1.4A� /,-%-=,' Z ,-',; R. M C B'RI DE a. %of Completed Work Subscribed and swu +: ore (. v \ �,-v, i 3ncocF� County (Column D+Eon G703) $ 70,435.00 me this �� Y 'f �j./'- � �' Al ��lyj`Y' (a,Q TIM tY 1 1-29-201 b. %of Stored Material Notary Public - . ,,' Co_._,T;,.,i0,_, . . 2 (Column F on G703) $ My Cribs s ss on expires: Total Retainage(Lines 5a+5b or Total in Column I of G703)., $ CERTIFICATE FOR PAYMENT 1,545,374.00 In accordance with the Contract Documents, based on on-site observations and the data comprising 6.TOTAL EARNED LESS RETAINAGE $ 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 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT $ ; 1,540,154.00 accordance with the Contract Documents,and the Contractor is entitled to payment of the AMOUNT (Line 6 from prior Certificate) CERTIFIED. 8.CURRENT PAYMENT DUE $ 5,220.00 AMOUNT CERTIFIED $�,�,7d-� 9.BALANCE TO FINISH,INCLUDING RETAINAGE (Attach explanation if amount certified differs from the amount applied.Initial all figures on this Application and on the Continuation Sheet that are changed to conform with the amount certified.) (Line 3 less Line 6) $ 75,325.00 CONSTRUCTION MANAGER: By. Date: . 1 CHANGE ORDER SUMMARY ADDITIONS ' DEDUCTIONS ARCHITECT: �� CSO ;rc n�J'V Total changes approved in previous months by Owner $ $ By: i Date: I 2 I/3!// Total approved this Month $ $ This Certificate is not negotiable. The AMOUNT CER f.F.UD is payable only to the Contractor TOTALS $ $ named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of NET CHANGES by Change Order $ the Owner or Contractor under this Contract. CAUTION: You should sign an original AIA,Contract Document,on which this text appears in RED. An original assures that changes will not be obscured. AIA Document G702/CMaTM'-1992.Copyright ©1992 by The American Institute of Architects.All rights reserved.WARNING:This AIA® Document is protected by U.S.Copyright Law and International Treaties. CONTINUATION SHEET Page2of4 • • APPLICATION NO. : 9 APPLICATION AND CERTIFICATE FOR PAYMENT, containing Contractor's signed Certification, is APPLICATION DATE: 11/30/2011 attached. In tabulations below, amounts are stated to the nearest dollar. Use Column I on Contracts where variable retainage for line items may apply. PERIOD TO: 11/30/2011 ARCHITECT'S PROJECT NO. : A B C D E F G H I WORK COMPLETED MATERIALS TOTAL ITEM PRESENTLY COMPLETED AND % BALANCE TO RETAINAGE DESCRIPTION OF WORK SCHEDULED VALUE FROM PREVIOUS FINISH (IF VARIABLE NO. APPLICATION THIS PERIOD STORED(NOT IN STORED TO DATE (G/C) (D+E) D OR E) (D+E+F) (C-G) RATE) 1 Allowance No. 1 -Base Bid Contingency $5,000.00 $5,000.00 $5,000.00 100% - 2 Allowance No. 2 -Winter Conditions $30,000.00 $30,000.00 $30,000.00_ 100% - 3 Allowance No. 3-Alternate 1 Contingency $5,000.00 $5,000.00 $5,000.00 100% - 4 Allowance No. 4-Alternate 2 Contingency $5,000.00 $5,000.00, $5,000.00 100% - 5 Allowance No. 5-Alternate 3 Contingency $5,000.00 $5,000.00 $5,000.00 100% - _ 6 Allowance No. 6-Alternate 4 Contingency $5,000.00 $5,000.00 $5,000.00 100% - 7 Bond $18,500.00 $18,500.00 $18,500.00 100% - 8 General Conditions $86,000.00 $86,000.00 $86,000.00 100% - 9 Site Clearing/Selective Site Demo $29,200.00 $29,200.00 $29,200.00 100% - 10 Earthwork $114,500.00 $114,500.00 $114,500.00 100% - 70,435.00 11 Stuctural Soil $7,800.00 $7,800.00 $7,800.00 100% - 12 Erosion/Sedimentation Control $500.00 $500.00 $500.00 100% - 13 Water Distribution $48,200.00 $48,200.00 $48,200.00 100% - 14 Storm Drainage $139,700.00 $139,700.00 $139,700.00 100% - 15 Asphalt Paving $16,900.00 $16,900.00 $16,900.00 100% - 16 Cast-in-Place Concrete-Mt'l $7,750.00 $7,750.00, $7,750.00 100% - 17 Cast-in-Place Concrete-Labor $6,350.00 $6,350.00 $6,350.00 100% - 18 Trench Drains- Mt'I $7,500.00 $7,500.00 $7,500.00 100% - 19 Trench Drains- Labor $2,300.00 $2,300.00 $2,300.00 100% - 20 Concrete Paving $156,454.00 $156,454.00 $156,454.00 100% - 21 Concrete Footing and Walls $43,900.00 $43,900.00 $43,900.00 100% - 22 Paving Joint Sealants $3,700.00 $3,700.00 $3,700.00 100% - 23 Unit Paver-Concrete $79,000.00 $79,000.00 $79,000.00 100% - 24 Permeable Unit Paving System - Concrete $65,000.00 $65,000.00 $65,000.00 100% - 25 Segmental Rataining Wall $25,000.00 $25,000.00 $25,000.00 100% - CONTINUATION SHEET Page 3 of 4 • APPLICATION NO. : 9 APPLICATION AND CERTIFICATE FOR PAYMENT, containing Contractor's signed Certification, is APPLICATION DATE: 11/30/2011 attached. In tabulations below, amounts are stated to the nearest dollar. Use Column I on Contracts where PERIOD TO: 11/30/2011 variable retainage for line items may apply. ARCHITECT'S PROJECT NO. : A B C ; D E F G H I WORK COMPLETED MATERIALS —ITEM TOTAL COMPLETED BALANCE TO DESCRIPTION OF WORK SCHEDULED VALUE FROM PREVIOUS PRESENTLY AND STORED TO % FINISH RETAINAGE NO. APPLICATION THIS PERIOD STORED(NOT IN (G/C) (IF VARIABLE RATE) (p+E) DORE) DATE(D+E+F) (C-G) 26 Bollards- Mt'l $5,050.00 $5,050.00 $5,050.00 100% - 27 Bollards- Labor $800.00 $800.00 $800.00 100% - 28 Masonry $9,000.00 $9,000.00 $9,000.00 100% - 29 Brick Masonry $7,000.00 $7,000.00 $7,000.00 100% - 30 Cast Stone $7,000.00 $7,000.00 $7,000.00 100% - 31 Pipe&Tube Railings-Steel $49,500.00 $49,500.00 $49,500.00 100% - 32 Water Repellants $700.00 $700.00 $700.00 100% - 33 Thermoplastic Membrane Waterproofing $76,000.00 $72,280.00 $3,720.00 $76,000.00 100% - 34 High Performance Pond Coatings-Mt'l $1,000.00 $1,000.00 _ $1,000.00 100% - 35 High Performance Pond Coatings-Labor $1,000.00 $500.00 $500.00 50% 500 36 Post& Panel Signs $5,300 5,300 $5,300.00 100% - 37 Fountain Structure-Mt'l $28,100 28,100 $28,100.00 100% - 38 Fountain Structure-Labor $800 800 $800.00 100% - 39 Fountain Plumbing- Mt'l $12,000 12,000 $12,000.00 100% - _ 40 Fountain Plumbing- Labor $3,000 3,000 $3,000.00 100% - 41 Electrical $223,000 218,610 $218,610.00 98% 4,390 42 Exterior Plants $8,200 8,200 $8,200.00 100% - 43 Tree Gates- Mt'l $9,846 9,846 $9,846.00 100% - 44 Tree Gates- Labor $1,400 1,400 $1,400.00 100% - 45 Bike Racks- Mt'l $900 900 900 100% - 46 Bike Racks- Labor $600 600 600 100% - 47 Planters - Mt'l $9,500 9,500 9,500 100% - 48 Planters- Labor $750 750 750 100% - 49 Change Order#1 $35,000 35,000 35,000 100% - 50 Change Order#2 $116,941 116,941 116,941 100% - CONTINUATION SHEET Page 4 of 4 • APPLICATION NO. : 9 APPLICATION AND CERTIFICATE FOR PAYMENT, containing Contractor's signed Certification, is APPLICATION DATE: 11/30/2011 attached. In tabulations below, amounts are stated to the nearest dollar. Use Column I on Contracts PERIOD TO: 11/30/2011 where variable retainage for line items may apply. ARCHITECT'S PROJECT NO. : A B C; D E F G H I WORK COMPLETED MATERIALS TOTAL ITEM SCHEDULED PRESENTLY COMPLETED AND °' BALANCE TO RETAINAGE NO. DESCRIPTION OF WORK VALUE FROM PREVIOUS FINISH APPLICATION THIS PERIOD STORED(NOT IN STORED TO DATE (G I C) (IF VARIABLE RATE) (D+E) D OR E) (D+E+F) (C G) 51 Change Order#3 -$20,000 (20,000) (20,000) 100% - 52 Change Order#4 $32,386 32,386 32,386 100% - 53 Change Order#5 $59,972 59,972 59,972 100% - 54 Change Order#6 $0 - 55 Change Order#7 $8,960 8,960 8,960 100% - 56 Change Order#8 $6,571 6,571 6,571 100% - 57 Change Order#9 -$10,600 (10,600) (10,600) 100% - 58 Change Order#10 $17,769 17,769 17,769 100% - 59 60 61 62 63 64 65 66 67 68 69 70 71 72 4 _ 73 • 74 _ 75 • $1,620,699 $1,610,589 $5,220 $0 $1,615,809 100% $4,890 $70,435 ISA Form#1-402 j f J ' # 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 Arts District Lofts Streetscape, Parcel 47 and owned by City of Carmel, Indiana. and does hereby further state on behalf of the aforementioned contractor: - (PARTIAL WAIVER) that there is due from the Owner the sum of ' . _ Five Thousand Two Hundred Twenty and No/100 Dollars ($5,220.00) ❑ 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 recei., of such payment. THERFORE, the undersigned waives and releases u to the r ner of said premises, any and all lien or claim whatsoever on the above-described property and improvements t I� eon. count of LABOR or material or both, furnished by the undersigned thereto, subject to limitations of conditio , f expr-.sed herein, if any; and further certifies that no other party has any claim or right to a lien on account of any wor, ±j•erfo ed or material furnished to the undersigned for said project, and within the scope of this affidavit and waiver. Gibraltar Construction Corp By / I I Title President frf WITNESS MY HAND AND NOTORIAL SE/., is 8t day of November, 2011. (Notary Public) c 1979 4N©BANA S1.i8CONTAACTOAS ASSOCIATION lNCOAPONA1f0 ttnaurnavted Alsp+odvcthon Prnn.bit.ed Re" 104 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 .6M7//„,, CV,//.:0 Purchase Order No. 2 9 32 k i%�1t�� /�'N� Terms 4'4, /47 KG 2/% Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) /d(3(/// -8 l�i� /2 y7 730. Co /i/3O/ — 9 4, 9 o„ /''7' 7 5220- Total l(9SG.e.)O _ I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I dit same in accordance with IC 5-11-10-1.6. — iii , 20 H asurer VOUCHER NO. WARRANT NO. ALLOWED 20 Cr r 9//1 9r o;as4'4,c Co' 2 9 3 2 /'i, - IN SUM OF $ I 7/12 itlG2/ $ ON ACCOUNT OF APPROPRIATION FOR Board Members PO#or INVOICE NO. ACCT#/TITLE AMOUNT DEPT.# I hereby certify that the attached invoice(s), or 902 e A-N6ay*-7 �,73O(o bill(s) is (are) true and correct and that the 9 1/41‘ob4'7 522 materials or services itemized thereon for which charge is made were ordered and received except / /27/ 20 // Executive Director Title Cost distribution ledger classification if claim paid motor vehicle highway fund Carmel Redevelopment Commission