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HomeMy WebLinkAboutKEYSTONE CONSTRUCTION- 002534- 12/22/2011Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL City Form No. 201 (Rev. 1995) 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 Ke yS +one COh5 .-ruk.c.-\-\ on Purchase Order No. Terms Date Due Invoice Date Invoice Number Description (or note attached invoice(s) or bill(s)) Amount $"--1 -0 9 N7 5-1-re45 alT (4 15 3111, a' 1 - :D -I 1 M rq- S -[1'.„1-5 Citi C di 9 SUS .' , Total Ll; g4b." I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I dance with IC 5- 11- 10 -1.6. 1� —)C ,2011 d' -ame in accor- easurer VOUCHER NO. WARRANT NO. K�v5-Fene ONcfion $ 2. it PM" ON ACCOUNT OF APPROPRIATION FOR a2 /1-1 46og 7 PO# or DEPT. # INVOICE NO. ACCT #/TITLE o E Pg.41 AMOUNT 15)341, °() 1)5 sn Cost distribution ledger classification if claim paid motor vehicle highway fund ALLOWED 20 IN SUM OF $ Board Members I hereby certify that the attached invoice(s), or 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 -S--2011 "1,74" Exec tErrector Title Carmel Redevelopment Commission Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL City Form No. 201 (Rev. 1995) 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 X+0, ..5. �� Cc)45. ✓dc 7, e)'7 c"-e,',0 Purchase Order No. l-1 7 S - A7,75, /vt, <r, 49 S7, Fe_ /6 Terms /yid, q��,D al;›, , /X2 '/6 20/ Date Due Invoice Date Invoice Number Description (or note attached invoice(s) or bill(s)) Amount I / - / 41 Io -67y %°5'7 57e fl -/ _; /E.76_ 77 Total 6 x'.627 • I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I • .1. -. •: me in accordance_ with IC 5- 11- 10 -1.6. , 20 it - Treasurer VOUCHER NO. WARRANT NO. 45/o j,0 cc, Cj/')C - $//(?/6 -77 ON ACCOUNT OF APPROPRIATION FOR PO# or DEPT. # INVOICE NO. ACCT #/TITLE AMOUNT 9v2 2N( os,y7 Cost distribution ledger classification if claim paid motor vehicle highway fund ALLOWED 20 IN SUM OF $ Board Members I hereby certify that the attached invoice(s), or 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 /2-/ 20// Xgnati ve Director Title Carmel Redevelopment Commission CARMEL REDEVELOPMENT COMMISSION Keystone Construction 47 South PA St, 10th Floor Indianapolis, IN 46204 Invoice. 10804 P47 site utilities 101009 P47 streetscape 101010 P47 streetscape P.O. Num. 002534 Check: 2534 Date: 12/22/2011 Vendor: KEYSTON1 Prior Invoice Amt Balance . Retention Discount Amt. Pak 1,846.77 1,846.77 0.00 0.00 1,846.7; 15,341.06 15,341.06 0.00 0.00 15,341.0E 9,505.80 9,505.80 0.00 .0.00 9505.8C HE.KEY TO�DOCUMENT SECURITY 4- H EAT'ACTI VATED;THUMBPRINT •w ADDITIONAL^ SECURITY FEATURES; INCLUDED, •.SEE ^BACK'FOR DETAILS', `C- liRMEC'Y° ' Carrriel -Redevelopment_Commission '30 West Main''Street`� 'Suite.220 �F. Carmel; IN 46032 f PAY TO THE - OF AMOUNT 12/22/2011 * * ** * * * * * *26, 693:63 THE SUM'OF TWENTY SIX THOUSAND SIX HUNDRED NINETY THREE. DOLLARS AND 63 CENTS * Keystone.Construction • 47?South PA St; 1'Oth Floor Indianapolis, IN'46204- 000 2 5 3 411® 1:0 740 14 2 1,3D: 008 7 504 i LIi° CARMEL REDEVELOPMENT COMMISSION Keystone Construction 47 South PA St, 10th Floor Indianapolis, IN 46204 Invoice 10804 P47 site utilities 101009 P47 streetscape ' 101010 P47 streetscape P.O. Num. 002534 Check: 2534 Date: 12/22/2011 Vendor: KEYSTON1 Prior Invoice Amt Balance Retention Discount Amt. Paid 1,846.77 1,846.77 0.00 0.00 1,846.77 15,341.06 15,341.06 0.00 0.00 15,341.06 9,505.80 9,505.80 0.00 0.00 9,505.80 26,693.63. ( -11- 52 COMPUTEREASE FORMS DIVISION (877)577 5791 '. T-37228 vI ® TM Document G7O2TM -1992 Application and Certificate for Payment TO OWNER: city of Larmel PROJECT: Parcel 4 / Site Utilities 110 W. Main Street Cannel, Indiana FROM CONTRACTOR: Keystone Construction Corpo►WPPRCHITECT: 47 S Pennsylvania Street FL 10 Indianapolis, IN 46204 APPLICATION NO: 1Q0804 PERIOD TO: 11/21/2011 CONTRACT FOR: CONTRACT DATE: PROJECT NOS: 1008 Distribution to: OWNER ARCHITECT CONTRACTOR FIELD OTHER 0 CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for payment, as shown below, in connection with the Contract. AIA Document G703TM, Continuation Sheet, is attached. 1. ORIGINAL CONTRACT SUM $ 2. NET CHANGE BY CHANGE ORDERS $ 3. CONTRACT SUM TO DATE (Line l ± 2) $ 4. TOTAL COMPLETED & STORED TO DATE (Column G on G703) $ 5. RETAINAGE: a. % of Completed Work (Columns D + E G703) $ b. % of Stored Material (Column F on G703) $ 25,902.77 0.00 25,902.77 25,902.77 Total Retainage (Lines 5a + 5b, or Total in Column I of G703) $ 6. TOTAL EARNED LESS RETAINAGE $ (Line 4 minus 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 minus Line 6) 0.00 25,902.77 24,056.00 1,846.77 0.00 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Total changes approved in previous months by Owner $ $ Total approved this month $ $ TOTAL $ $ NET CHANGES b Chan•e Order $ 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 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. CONTR K ystone Construction Corporation • By: State 0 County of: rYt•o,-.tr -- Subscribed and sworn :to before' ' me this a( a.:- day of 'NO It Date: qa! /!/ Notary Public: My commission expires: NY_ ANDREA M. ROELL NOTARY PUBLIC SEAL STATE OF INDIANA MARION COUNTY MY COMMISSION EXPIRES: NOVEMBER 8, 2016 ARCHITECT'S CERTIFICATE FOR PAYMENT In accordance with the Contract Documents, based on on -site observations and the data comprising this application, the Architect certifies to the Owner that to the best of the Architect's 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. AMOUNT CERT D (Attach expla ration if am -e c•erti d differs from the amount applied. Initial all figures on this Applicatioi and on the i ntinuatio Sheet that are changed to conform with the amount certified.) ARCHITE ' T: $r.. %7 By: Date: / / /;Q2,/ This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issiiance payment and acceptance of payment are without prejudice to any rights of 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 G702TM — 1992. Copyright © 1953, 1963, 1965, 1971, 1978, 1983 and 1992 by The American Institute of Architects. All rights reserved. WARNING: This Ale Document is protected by U.S. Copyright Law�`'{t and International Treaties. Unauthorized reproduction or distribution of this Ale Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent Y possible under the law. Purchasers are permitted to reproduce ten (10) copies of this document when completed. To report copyright violations of AIA Contract Documents, e-mail The American Institute of Architects' legal counsel, copyright @aia.org. *4AIAAIM II Document G702TM -1992 Instructions Application and Certificate for Payment GENERAL INFORMATION Purpose and Related Documents. AIA Document G702, Application and Certificate for Payment, is to be used in conjunction with AIA Document G703TM, Continuation Sheet. These documents are designed to be used on a Project where a Contractor has a direct Agreement with the Owner. Procedures for their use are covered in AIA Document A201 TM, General Conditions of the Contract for Construction. Use of Current Documents. Prior to using any AIA Contract Document, users should consult www.aia.org or a local AIA component to verify the most recent edition. Reproductions. This document is a copyrighted work and may not be reproduced or excerpted from without the express written permission of the AIA. There is no implied permission to reproduce this document, nor does membership in The American Institute of Architects confer any further rights to reproduce this document. The AIA hereby grants the purchaser a limited license to reproduce a maximum of ten copies of a completed G702, but only for use in connection with a particular project. The AIA will not permit reproduction outside of the limited license for reproduction granted above, except upon written request and receipt of written permission from the AIA. Rights to reproduce the document may vary for users of AIA software. Licensed AIA software users should consult the End User License Agreement (EULA). To report copyright violations of AIA Contract Documents, e -mail The American Institute of Architects' legal counsel, copyright @aia.org. COMPLETING G702 After the Contractor has completed AIA Document G703, Continuation Sheet, summary information should be transferred to AIA Document G702, Application and Certificate for Payment. The Contractor should sign G702, have it notarized, and submit it, together with G703, to the Architect. The Architect should review G702 and G703 and, if they are acceptable, complete the Architect's Certificate for Payment on G702. The Architect may certify a different amount than- that applied for, pursuant to Sections 9.5 and 9.6 of A201. The Architect should then initial all figures on G702 and G703 that have been changed to conform to the amount certified and attach an explanation. The completed G702 and G703 should be forwarded to the Owner.' MAKING PAYMENT The Owner should make payment directly to the Contractor based on the amount certified by the Architect.on AIA Document G702, Application and Certificate for Payment. The completed form contains the name and address of the Contractor. Payment should not be made to any other party unless specifically indicated on G702. ' EXECUTING THE DOCUMENT j Persons executing the document should indicate the capacity in which they are acting (i.e., president, secretary, partner, etc.) and the authority under which they are executing the docurntent. Where appropriate, a copy of the resolution authorizing the individual to act on behalf of the firm or entity should be attached. ■ I F; AIA Document G702TM —1992. Copyright © 1953, 1963, 1965, 1971, 1978, 1983 and 1992 by The American Institute of Architects. All rights reserved. WARNING: This AIA® Document is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA® Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. Purchasers are permitted to reproduce ten (10) copies of this document when completed. To report copyright violations of AIA Contract Documents, e-mail The American Institute of Architects' legal counsel, copyright @aia:org a AI Continuation Sheet Document G703TM - 1992 ............... AIA Document G702TM -1992, Application and Certificate for Payment, or G732TM -2009, Application and Certificate for Payment, Construction Manager as Adviser Edition, containing Contractor's; signed certification is attached. In tabu ations below, : amounts are in US dollars. Use Column ,I on Contracts where variable retainage for line items may apply. APPLICATION NO: APPLICATION DATE: PERIOD TO: ARCHITECT'S PROJECT NO: 100804 11/21/2011 11/21/2011 1008 A B C D E G H ITEM NO. DESCRIPTION OF WORK SCHEDULED VALUE WORK COMPLETED FROM PREVIOUS APPLICATION (D + E) THIS PERIOD 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 (!f variable rate) 1 2 General Conditions to Date 5% Cons Management Fee to C 19, 320.59 6,582.18 17,681.00 6,375.00 1,639.59 207.18 19,320.5E 6,582.1E 100.0 0 100.01 Totals GRAND TOTAL 25,902.77 24,056.0C 1,846.77 25,902.77 100.0 0 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 G703TM — 1992. Copyright © 1963, 1965, 1966, 1967, 1970, 1978, 1983 and 1992 by The American Institute of Architects. All rights reserved. WARNING: This Ale Document is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA® Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. Purchasers are permitted to reproduce ten (10) copies of this document when completed. To report copyright violations of AIA Contract Documents, e -mail The American Institute of Architects' legal counsel, copyright @aia.org. 101210ACD44 — o �`��� Doc ument G7O3TM- 1992 In structions Continuation Sheet GENERAL INFORMATION Purpose and Related Documents. AIA Document G703TM, Continuation Sheet, is to be used in conjunction with AIA Document G702TM' Application and Certificate for Payment, or AIA Document G732T51, Application and Certificate for Payment, Construction Manager as Adviser Edition. These documents are designed for use on Projects where the Contractor has a direct Agreement with the Owner. Procedures for their use are covered in AIA Documents A201 TM, General Conditions of the Contract for Construction, and A232Tm, General Conditions of the Contract for Construction, Construction Manager as Adviser Edition. Use of Current Documents. Prior to using any AIA Contract Document, users should consult www.aia.org or a local AIA component to verify the most recent edition. Reproductions. This document is a copyrighted work and may not be reproduced or excerpted from without the express written permission of the AIA. There is no implied permission to reproduce this document, nor does membership in The American Institute of Architects confer any further rights to reproduce this document. The AIA hereby grants the purchaser a limited license to reproduce a maximum of ten copies of a completed G703, but only for use in connection with a particular project. The AIA will not permit reproduction outside of the limited license for reproduction granted above, except upon written request and receipt of written permission from the AIA. Rights to reproduce the document may vary for users of AIA software. Licensed AIA software users should consult the End User License Agreement (EULA). To report copyright violations of AIA Contract Documents, e -mail The American Institute of Architects' legal counsel, copyright @aia.org. COMPLETING G703 -1992 Heading. This information should be completed in a manner consistent with similar information on AIA Document G702, Application and Certificate for Payment, or G732T51, Application and Certificate for Payment, Construction Manager as Adviser Edition, whichever is applicable. Columns A, B and C. These columns should be completed by identifying the various portions of the Project and their scheduled values consistent with the schedule of values submitted to the Architect at the commencement of the Project or as subsequently adjusted. The breakdown may be by sections of the Work or by Subcontractors and should remain consistent throughout the Project. Multiple pages should be used when required. Column C should be subtotaled at the bottom when more than one page is used and totaled on the last page. Initially, this total should equal the original Contract Sum. The total of column C may be adjusted by Change Orders during the Project. Column D. Enter in this column the amount of completed Work covered by the previous application (columns D & E from the previous application). Values from column F (Materials Presently Stored) from the previous application should not be entered in this column. Column E. Enter here the value of Work completed at the time of this application, including the value of materials incorporated in the project that were listed on the previous application under Materials Presently Stored (column F). Column F. Enter here the value of Materials Presently Stored for which payment is sought. The total of the column must be recalculated at the end of each pay period. This value covers both materials newly stored for which payment is sought and materials previously stored which are not yet incorporated into the Project. Mere payment by the Owner for stored materials does not result in a deduction from this column. Only as materials are incorporated into the Project is their value deducted from this column and incorporated into column E (Work Completed —This Period.) Column G. Enter here the total of columns D, E and F. Calculate the percentage completed by dividing column G by column C. Column H. Enter here the difference between column C (Scheduled Value) and column G (Total Completed and Stored to Date). Column 1. This column is normally used only for contracts where variable retainage is permitted on a line -item basis. It need not be completed on projects where a constant retainage is withheld from the overall contract amount. Change Orders. Although Change Orders could be incorporated by changing the schedule of values each time a Change Order is added to the Project, this is not normally done. Usually, Change Orders are listed separately, either on their own G703 form or at the end of the basic schedule. The amount of the original contract adjusted by Change Orders is to be entered in the appropriate location on the G702 or G732 form, whichever is applicable. Construction Change Directives. Amounts not in dispute that have been included in Construction Change Directives should be incorporated into one or rriore Change Orders. Amounts remaining in dispute should be dealt with according to Section 7.3 of AIA Document A201 or Section 7.3 of AIA Document A232. The following is an example ofa Conti nation Sheet for work in progress. Please note that dollar amounts shown below are for illustrative purposes only, and are not intended to reflect actual constriction costs. AIA Document G703TM" –1992. Copyright © 1963, 1965, 1966, 1967, 1970, 1978, 1983 and 1992 by The American nstitute of Architects. All rights reserved. WARNING: This AIA® Document is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA® Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. Purchasers are permitted to reproduce ten (10) copies of this document when completed. To report copyright violations of AIA Contract Documents, e -mail The American Institute of Architects' legal counsel, copyright @aia.org. ITEM NO. DESCRIPTION OF WORK SCHEDULED VALUE MATERIALS PRESENTLY STORED Oa11DrxE) TOTAL COMPLETED AND STORED TO DATE (D +E +Ej % (G L) BALANCE TO FINISH (C — G) RIiTAINAGE ( /J�oriable rare) FROM PREVIOUS APPLICATION (D + E) THIS PERIOD 1 MOBILIZATION 5000 5,000 0 0 5,000 100 0 2 STUMP REMOVAL 5 000 5,000 0 0 5,000 100 0 3 EARTH WORK 15000 10,000 5,000 0 15,000 100 0 4 LOWER RETAINING WALL 10000 0 5,000 0 5,000 50 5,000 5 CURBS & MISC. CONC. 5,000 0 0 0 0 0 5,000 6 PAVING, UPPER DRIVE 20,000 0 0 0 0 0 20,000 7 PAVING, LOWER DRIVE 20,000 0 0 0 0 0 20,000 8 PAVERS 20000 0 0 10,000 10,000 50 10,000 9 BRICK WORK 5000 0 0 0 0 0 5,000 10 11 GRAND TOTAL 105,000 20,000 10,000 10,000 40,000 65,000 AIA Document G703TM" –1992. Copyright © 1963, 1965, 1966, 1967, 1970, 1978, 1983 and 1992 by The American nstitute of Architects. All rights reserved. WARNING: This AIA® Document is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA® Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. Purchasers are permitted to reproduce ten (10) copies of this document when completed. To report copyright violations of AIA Contract Documents, e -mail The American Institute of Architects' legal counsel, copyright @aia.org. AFFIDAVIT AND WAIVER OF LIEN Final State of Indiana, County of Marion. SS: Partial X Payment to Follow Christi Minars, being duly sworn, states that he is Controller of Keystone Construction Corporation (Contractor) having contracted with City of Carmel to furnish certain materials and /or labor as follows for a project known as Parcel 47, Site Utilities, located at 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 Dollars ( $ [ ] 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 One Thousand Eight Hundred Forty Six & 77/100 Dollars ( $ [ ] receipt of which is hereby acknowledged; or 1,846.77 ). [ X] 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. THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all lien or claim whatsoever on the above - described property and improvements thereon on account of LABOR or MATERIAL or both, furnished by the undersigned thereto, subject to limitations or conditions expressed herein, if any; and further certifies that no other party has any claim or right to a lien on account of any work performed or material furnished to affidavit and waiver. Keystone Construction Corporation (Company) un. - . igned for said project, and within the scope of this (Authorize( Representative) Title Controller WITNESS HAND AND NO IAL SEAL, this a l 1 4 ) — day of yl 61-4)4414-6 4A--201 1. Notary Public: Printed Nanic: Andrea M. Rocll re Of Indiana County of Marion vI Commission I:spires November 8. 2(116 ANDREA M. ROELL NOTARY PUBLIC SEAL STATE GE INDIANA MARION COUNTY MY COMMISSION EXPIRES: NOVEMBER 8. 20(6 APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE 1 OF 3 PAGES TO OWNER: PROJECT: Parcel 47 Streetscape City of Carmel Cannel, Indiana FROM CONTRACTOR: Keystone Construction Corp. 47 S. Pennsylvania Street Indianapolis, IN 46204 CONTRACT FOR: VIA ARCHITECT: APPLICATION NO: PERIOD TO: PROJECT NOS: CONTRACT DATE: 101009 8/31/11 1010 Distribution to: OWNER ARCHITECT CONTRACTOR CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for payment, as shown below, in connection with the Contract. Continuation Sheet, AIA 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. % of Completed Work $ (Column D + E on G703) b. 10 % of Stored Material $ (Column F on G703) Total Retainage (Lines 5a + 5b or Total in Column 1 of G703) 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) $ 137,370.00 $ 15,194.10 $ 152,564.10 $ 152.564.10 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 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. CONTRACTOR: KEYSI' E CO►_TRUCTION CORPORATION i AI I State of: Ins ' • I County of: M Subscribed and sworn to before me this st da , of Dec( 0.00 Notary Public: iw c-1yj n My Commission expires: I3y: Date: 8/26/2011 Revised 12/1/11/2011 ANDREA M. ROELL rion NOTARY PUBLIC nber, 2011 SEAL STATE OF INDIANA MARION COUNTY MY COMMISSION EXPIRES: 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT In accordance with the Contract Documents, based on on -site observations and the data comprising the application, the Architect certifies to the Owner that to the best of the Architect's 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. $ 152,564.10 $ 137,223.04 $ 15,341.06 0.00 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Total changes approved in previous months by Owner Total approved this Month $15,194.10 TOTALS $15,194.10 $0.00 NET CHANGES by Change Order $15,194.10 AMOUNT CERTIFIED ' ,04' (Attach explanatio a count certified differs from the amount applied. Initial all figures on this Application a onthe ontinu on Sheet that are changed to conform with the amount certified.) ARCHITE By: Date: w This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the contractor named herein. Issuance, payment and acceptance 01 payment are without 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. - CONTINUATION SHEET AIA DOCUMENT G703 PAGE 2 OF 2 PAGES AIA 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 APPLICATION NO: APPLICATION DATE: PERIOD TO: PROJECT NO: 101009 8/26/2011 REV 12/1/11 8/31/2011 1010 A B C D E F G H I ITEM NO. DESCRIPTION OF WORK SCHEDULED VALUE 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) FROM PREVIOUS APPLICATION (D + E) THIS PERIOD 1 General Conditions & CM Fee $137,370.00 $137,223.04 $146.96 - $137,370.00 100% $0.00 2 Change Order #1 $3,500.00 $3,500.00 - $3,500.00 100% $0.00 3 Change Order #2 $ 1 1,694.10 -. $11,694.10 - $11,694.10 100% $0.00 - PAGE TOTAL $152,564.10 $137,223.04 $15,341.06 $0.00 $152,564.10 100% $0.00 _ Users may obtain validation of this document by requesting of the license a completed AIA Document D401 - Certification of Document's Authenticity AFFIDAVIT AND WAIVER OF LIEN Final Partial Payment to Follow State of Indiana, County of Marion. SS: Bob Crowder, being duly sworn, states that she is the Project Director of Keystone Construction Corporation (Contractor) having contracted with Carmel Redevelopment Commission to furnish certain materials and /or labor as follows for a project known as Parcel 47 Streetscape, located at Carmel Indiana and does hereby further state on behalf of the aforementioned Contractor. X X (PARTIAL WAIVER) that there is due from the owner the sum of Fifteen Thousand Three Hundred Forty One & 06/100 Dollars ($ 15,341.06 ) [ ] receipt of which is hereby acknowledged ; or [ X ] 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. THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all lien or claim whatsoever on the above - described property and improvements thereon on account of LABOR or MATERIAL or both, furnished by the undersigned thereto, subject to limitations or conditions expressed herein, if any; and further certifies that no other party has any claim or right to a lien on account of any work performed or material furnished to the under gned for said oject, and within the scope of this affidavit and waiver. Keystone Construction Corporation By (Company) wri:�$V R sentative) Title Project Director WITNESS MY HAND AND NOTARIAL SEAL, this 1st day of December, 2011. Notary Public: Printed Name: Andrea M. Rod' DR M. "0-(5t 1. nA wuuo' NUTi4RY'v p�i4Cmiission rXpires SEAL STATE OF INDIANA MARION COUNTY MY COMMISSION EXPIRES: NOVEMBER 8, 2016 I Marion :ovember 8. 2016 APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE 1 OF 3 PAGES TO OWNER: City of Carmel FROM CONTRACTOR: Keystone Construction Corp. 47 S. Pennsylvania Street Indianapolis, IN 46204 CONTRACT FOR: PROJECT: Parcel 47 Streetscape Carmel, Indiana VIA ARCHITECT: APPLICATION NO: PERIOD TO: PROJECT NOS: CONTRACT DATE: 101010 9/30/11 1010 Distribution to: OWNER ARCHITECT CONTRACTOR CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for payment, as shown below, in connection with the Contract. Continuation Sheet, AIA Document G703, is attached. L 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. % of Completed Work $ (Column D + E on G703) b. 10 % of Stored Material $ (Column F on G703) Total Retainage (Lines 5a + 5b or Total in Column 1 of 6703) 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) $ 137,370.00 $ 24,699.90 $ 162,069.90 $ 162,069.90 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 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. CONTRACTOR: By: KE TO L CONSTRUCTION CORPORATION State of: In lam Subscribed and sworn to before me this 0.00 Notary Public: '' My Commission expires: Date: 10/3/2011 Revised 12/1/2011 County of: Marion day of Dec'n hrr 7011 ANDREA M, ROELL NOTARY PUBLIC SEAL $ 0.00 ARCHITECT'S CERTIFICATE FOR $ 162,069.90 In accordance with the Contract Documents, based on on -site comprising the application, the Architect certifies to the Own - Architect's 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 9,505.80 is entitled to payment of the AMOUNT CERTIFIED. $ 152,564.10 PAYMENT'AJ1ON coin observations arifa'titearttiiISSION EXPIRES:. 1^;r that to the best oNQMBER 8, 2016 0.00 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Total changes approved in previous months by Owner $15,194.10 Total approved this Month $9,505.80 TOTALS $24,699.90 $0.00 NET CHANGES by Change Order $24,699.90 AMOUNT CERTIFIED (Attach explana Application a ARCHITEC $ 71 505 e, ount certified differs from the amount applied. Initial all figures on this ontinc ptiQj1 Sheet that are changed to conform with the amount certified.) By: ( .,L �' Date: /2/1724, This Certiticatc is not negotiable. The AMOUNT CERTIFIED is payable only to the named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract. erP 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. CONTINUATION SHEET A1A DOCUMENT G703 PAGE 2 OF 2 PAGES AIA 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. APPLI A ION NO: APPLICATION DATE: PERIOD TO: PROJECT NO: 101010 REVISION #2 9/30/2011 Rev 12/1/11 1010 A B C D E F G 1 -I I ITEM NO. DESCRIPTION OF WORK SCHEDULED VALUE 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) FROM PREVIOUS APPLICATION (D + E) TI -IIS PERIOD 1 General Conditions & CM Fee $137,370.00 $137,370.00 -- $137,370.00 100% $0.00 2 Gilbraltar Change Order #1 $3,500.00 $3.500.00 -- $3,500.00 100% $0.00 3 Gilbraltar Change Order #2 $11,694.10 $11,694.10 -- $1 1,694.10 100% $0.00 4 Gilbraltar Change Order #3 - $2,000.00 - $2,000.00 — - $2,000.00 100% $0.00 5 Gilbraltar Change Order #4 $3,238.60 $3,238.60 -' $3,238.60 100% $0.00 Gilbraltar Change Order #5 $5,997.20 $5,997.20 - $5,997.20 100% $0.00 Gilbraltar Change Order #6 $0.00 -- $0.00 0% $0.00 Gilbraltar Change Order #7 $896.00 $896.00 — $896.00 100% $0.00 Gilbraltar Change Order #8 $657.10 $657.10 — $657.10 100% $0.00 Gilbraltar Change Order 49 - $1,060.00 - $1,060.00— - $1,060.00 100% $0.00 Gilbraltar Change Order #10 $1,776.90 $1,776.90 — $1,776.90 100% $0.00 - PAGE TOTAL $162,069.90 $152,564.10 $9,505.80 $0.00 $162,069.90 100% $0.00 Users may obtain validation of this document by requesting of the license a completed AIA Document D401 - Certification of Document's Authenticity AFFIDAVIT AND WAIVER OF LIEN Final Partial Payment to Follow State of Indiana, County of Marion. SS: Bob Crowder, being duly sworn, states that she is the Project Director of Keystone Construction Corporation (Contractor) having contracted with Carmel Redevelopment Commission to furnish certain materials and /or labor as follows for a project known as Parcel 47 Streetscape, located at Carmel Indiana and does hereby further state on behalf of the aforementioned Contractor. X X (PARTIAL WAIVER) that there is due from the owner the sum of Nine Thousand Five Hundred Five & 80/100 Dollars ($ 9,505.80 [ ] receipt of which is hereby acknowledged ; or [ X ] 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. THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all lien or claim whatsoever on the above - described property and improvements thereon on account of LABOR or MATERIAL or both, furnished by the undersigned thereto, subject to limitations or conditions expressed herein, if any; and further certifies that no other party has any claim or right to a lien on account of any work performed or material furnished to the undersig d for said prosy t, and within the scope of this affidavit and waiver. Keystone Construction Corporation By Title Project Director (A ative) (Company) WITNESS MY HAND AND NOTARIAL SEAL, this 1st day of December, 2011. Notary Public: Printed Name: Andrea M. RoelI t•I State of Indiana County of Marion ANDREA OELLitisi NOTARY UI8L7 on Ixpires ti'ovembcr 8.20 16 P SEAL STATE OF INDIANA MARION COUNTY MY COMMISSION EXPIRES: NOVEMBER 8, 2016