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HomeMy WebLinkAboutKEYSTONE CONTRUCTION- 002287- 9/22/2011 CARMEL REDEVELOPMENT COMMISSION 002287 Keystone Construction Check: 2287 47 South PA St, 10th Floor Date: 9/22/2011 Indianapolis, IN 46204 Vendor: KEYSTON1 Prior Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid 101004 22,518.90 22,518.90 0.00 0.00 22,518.90 Application 4 P47 Streetscape y11q(o(ol 101008 n 3,646.96 3,646.96 0.00 0.00 3,646.96 Retainage on P47 Ip 9 50 tl' 26,165.86 26,165.86 0.00 0.00 26,165.86 '. THE KEY TO DOCUMENT SECURITY+HEAT ACTIVATED THUMB PRINT'¢?ADDITIONALSECURITyYLFEATUR SINCLrUDEMSEE BACKtFORiD ETAIliS ?'s a°1- Carmel Redevelopment Con- 'ssion 002287 30 West Main Street REGION. '0 Suite 220 20-1421/740 e::: / Carmel, IN 46032 I D. E / A 287 III 7 2/201 "' "'• •1165.86 PAY THE SUM OF TWENTY SIX THOUSAND ONE HU DRED D 7 ' IVE II I. •P SAN I 8r CE TS*" TO THE I ORDER OF Keystone Construction 'r �`_. , . _..../ 47 South PA St, 10th Floor ' Indianapolis, IN 46204 ✓n.', M• '' sue. u 0022870 1:0740L42131: 0087504LLLux CARMEL REDEVELOPMENT COMMISSION 002287 Keystone Construction Check: 2287 47 South PA St, 10th Floor Date: 9/22/2011 Indianapolis, IN 46204 Vendor: KEYSTON1 Prior Invoice P.O. (Num. Invoice Amt Bal. ce Rete iion Discount Amt. Paid 101004 22,518.90 22,5&' •0 •100 0.00 22,518.90 Application 4 P47 Streetscape 101008 3, 46.96 3,:i• • '• 01161 0.00 3,646.96 Retainage on P47 26,165. 6 26,1:. :: 0.00 0.00 26,165.86 X41-52 COMPUTEREASE FORMS DIVISION(877)577.5791 1-37228 1, CARMEL REDEVELOPMENT COMMISSION Keystone Construction 47 South PA St, 10th Floor Indianapolis, IN 46204 002287 Check: 2287 Date: 9/22/2011 Vendor: KEYSTON1 Prior Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid 101004 22,518.90 22,518.90 0.00 0.00 22,518.90 Application 4 P47 Streetscape 101008 3;646.96 3,646.96 0.00 0.00 3,646.96 Retainage on P47 THE.KEY TO DOCUMENT SECURITY„ HEAT ACTIVATEDTHUMB PRINT `•-ADDITIONAL' SECURITY FEATURES:INCLUDED 'SEE BACK,F,OR DETAILS is 6.Des PAY TO THE ORDER OF Carmel .Redevelopment Commission 30 Wet Mann: Street` Suite 220 armel; IN 46032 THE ;SUM:0 ► REGIONS -20 `1421/740 DATE '- 002287 / Ylf AMOUNT 2287 * * * * * * * * * * - - 9/22/2011 - 26,165;86" TWENTY SIX THOUSAND ONE HUNDRED SIXTY FIVE'DOLLARS AND 86 CENTS ** *,* Keystone -` 47,South PA St, 1 0th °Floor Indianapolis, IN 46204 ry • 0002287(+' I :074004213I: 0087504LLL11® CARMEL REDEVELOPMENT COMMISSION Keystone Construction 47 South PA St, 10th Floor Indianapolis, IN 46204 Invoice P.O. Num. 101004 Application 4 P47 Streetscape 101008 Retainage on P47 X -11- 52 COMPUTEREASE FORMS DIVISION (877)577 =5791 T -37228 002287 Check: 2287 Date: 9/22/2011 Vendor: KEYSTON1 Prior Invoice Amt Balance Retention Discount Amt. Paid 22,518.90 22,518.90 0.00 0.00 22,518.90 3,646.96 3,646:96 0.00 0.00 3,646:96 26,i 65.86 26,165.86 0.00 0:00 26,165.86 ,CARMEL REDEVELOPMENT COMMISSION Keystone Construction 47 South PA St, 10th Floor Indianapolis, IN 46204 Invoice P.O. Num. 101004 Application 4 P47 Streetscape Invoice Amt 22,518.90 002335 Check: 2335 Date: 9/29/2011 Vendor: KEYSTON1 I Prior Balance Retention Discount 22,518.90 0.00 0.00 Amt. Pai 22,518.9 22,518.90 22,51.8.90 0.00 0.00 22,518.9 THE KEY TOT DOCUMENT SECURITY +H,EAT'ACTIVATED•THUM &PRINT ,r ADDITIONAL, SECURITY FEATURES INCLUDED ;SEE BACK ? FOR: DETAILS;° Carmel Redevelopment Commission 30 West Main 'Street Suite 220 Carmel; IN 46032 4 J EGIONS 20- 1421/740 00.;2335 AMOUNT 2335 9/29/2011 * * *" * * * ** *22,518:90. PAY THE SUM OF TWENTY TWO THOUSAND FIVE HUNDRED EIGHTEEN DOLLARS AND 90 CENTS * ** TO THE ORDER OF Keystone Construction, 47 South PA St, 10th °Floor Indianapolis', IN 46204 000 233 So 1:074014 2 31: 0087504 REDEVELOPMENT COMMISSION Keystone Construction 47 South PA St, 10th Floor Indianapolis, IN 46204 Invoice P.O. Num. 101004 Application 4 P47 Streetscape 002335 Check: 2335 Date: 9/29/2011 Vendor: KEYSTON1 Prior Invoice Amt Balance Retention Discount Amt. Paid 22,518.90 22,518.90 0.00 0.00 22,518.90 22,518.90 22,518.90 0.00 0.00 22,518.90 • X-11-52 COMPUTEREASE FORMS DIVISION (877)577 - 5791 ^ T -37228 CARMEL REDEVELOPMENT COMMISSION Keystone Construction 47 South PA St, 10th Floor Indianapolis, IN 46204 002336 Check: 2336 Date: 9/29/2011 Vendor: KEYSTON1 Prior Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid 101008 3,646.96 3,646.96 0.00 0.00 3,646.96 Retainage on P47 3,646.96 3,646.96 0.00 0.00 3,646.96 THE KEY TO DOCUMENT SECURITY,.' HEAT ACTIVATED. THUMB' PRINT • ADDITIONAL SECURITY FEATURES INCLUDED SEE BACK: FOR' DETAILS. Carmel Redevelopment Commission 30-West Main Street. Suite 220 Carmel, IN 46032 A REGIONS 20- 1421)740 002336 DATE AMOUNT 2336 9/29/2011 ***********3,646.96 PAY THE SUM OF THREE THOUSAND SIX HUNDRED FORTY SIX DOLLARS AND 96 CENTS * * * * * * * * * * * ** TO THE ORDER OF Keystone Construction 47 South PA St, 10th Floor Indianapolis, IN 46204 11 °00233610' 1 :0740L421,34: 00875011 L Li�° CARMEL REDEVELOPMENT COMMISSION Keystone Construction 47 South PA St, 10th Floor Indianapolis, IN 46204 Invoice 101008 Retainage on P47 P.O. Num. :•71- 52 COMPUTEREASE FORMS DIVISION (877)577 -5791 T -37228 002336 Check: 2336 Date: 9/29/2011 Vendor: KEYSTON1 Prior Invoice Amt Balance Retention Discount Amt. Paid 3,646.96 3,646.96 0.00 0.00 3,646.96 3,646.96 3,646.96 0.00 0.00 3,646.96 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 Cannel, Indiana VIA ARCHITECT: APPLICATION NO: 101008 PERIOD TO: 7/31/11 PROJECT NOS: 1010 CONTRACT DATE: 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 I 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 $ 3,500.00 $ 140,870.00 $ 140,870.00 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. CO KEYSTONE CONSTRUCTION CORPORATION By: Date: 8/26/2011 State of: Indiana County of: Mari n Subscribed an sworn to bef' = me 1 26 day of August 2011 0.00 Notary Public. , My Commission expires: 0.00 140,870.00 $ 137,223.04 $ 3,646.96 0.00 CHAN E ORDER SUMMARY ADDITIONS DEDUCTIONS Total changes approved in previous months by Owner Total approved this Month $3,500.00 TOTALS $3,500.00 $0.00 NET CHANGES by Change Order $3,500.00 ARCHITECT'S CERTIFICATE FOR ANDREA M. ROELL NOTARY PUBLIC SEAL STATE OF INDIANA MARION COUNTY h�MvuoOwly tXYIKtS: 1 EN NOVEMBER 8, 2016 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. AMOUNT CERTIFIED $ (Attach explan Application ARCHITE By: ount certified differs from the amount applied. Initial all figures on this ontinuati Sheet that are changed to conform with the amount certified.) Date: SASli r This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, payment and acceptance or 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. yy6,051= / /OC% 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 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 -_ PAGE TOTAL $140,870.00 $137,223.04 $3,646.96 $140,870.00 100% $0.00 Users may obtain validation of this document by requesting of the license a completed AIA Document D401 - Certification of Document's Authenticity AFFIDAVIT AND WAIVER OF LIEN Final Partial X Payment to Follow State of Indiana, County of Marion. SS: Christi Minars, being duly sworn, states that she is the Controller of Keystone Construction Corporation (Contractor) having contracted with Carmel Redevelopment Commission to furnish certain materials and /or labor as follows for a project known as Parcel 47 Streetscape, located at Carmel Indiana and does hereby further state on behalf of the aforementioned Contractor. X (PARTIAL WAIVER) that there is due from the owner the sum of Three Thousand Six Hundred Forty Six & 96/100 [ ] receipt of which is hereby acknowledged ; or Dollars ($ 3,646.96 [ 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 undersigned for said project, and within the scope of this affidavit and waiver. Keystone Construction Corporation 1 u Title Controller (Company) WITNESS M n Notary Public: (Authorized Representative) HAND AND NOTARIAL SEAL, this 26th day of August, 2011. Printed Name: Andrea M State of Indiana County of Marion Roell ANDREA M. ROELL My Commissioi NOTARY PUBLIC SEAL STATE OF INDIANA MARION COUNTY MY COMMISSION EXPIRES: NOVEMBER 8, 2016 Expires November 8. 2016 TM Document G702 -1992 Application and Certificate for Payment TO OWNER:City of Carmel PROJECT: Parcel 47 Streetscane Carmel, Indiana FROM CONTRACTOR: VIA ARCHITECT: Keystone Construction Corporation 47 S Pennsylvania Street FL 10 Indianapolis, IN 46204 APPLICATION N°:101004 PERIOD TO: CONTRACT FOR CONTRACT DATE: PROJECT NOS: 1010 Distribution to: OWNER ❑ ARCHITECT ❑ CONTRACTOR ❑ FIELD ❑ OTHER ❑ 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 (Lint 1 ± 2) $ 4. TOTAL COMPLETED & STORED TO DATE (Column G on G703) $ 5. RETAINAGE: a• % of Completed Work (Columns D + Eon G703) $ b. % of Stored Material (Column F on G703) $ 42.216 30 0.00 '13,216.30 X3.216.30 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 43)1630 70 697 40 77 SIR 90 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. • CONTRACTO By: State of: Indiana County of:Marion eysto • Construction Corporation Subscribed and sworn before me this aS` 1— day of Notary Public: My commission expires: Date: 31as�t U11 ANDREA M. ROELL NOTARY PUBUC SEAL STATE OF INDIANA MARION COUNTY MY COMMISSION BER B 2016 ARCHITECTS CERTIFICATE T 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 CERTIFIED $ it trjl$ 90 (Attach explan a if amount certified differs from the amount applied. Initial all figures on this Application end i the CF uation Sheet that are changed to conform with the amount certified) ARCHITE By: This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein:. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract. Date: 31a5 f it 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 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. / [_ Director of Redevelopment / yd0j 97 2-AIDocument G702 TM -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 ALA 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 ALA 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 A20'1. 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 t 1 Persons executing the document should indicate the capacity; in which they Ore acting (i.e., president, secretary, partner, etc.) and the authority under which they are executing the document. Where appropriate, a copy of the resolution authorizing the individual to act on behalf of the firm or entitfshould be attached. E•-.! 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 AlA® 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. Continuation Sheet Document 6703 TM -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 101004 APPLICATION DATE: 3/25/2011 PERIOD TO 3/31/2011 ARCHITECT'S PROJECT NO: 1010 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 (If variable rate) 1 2 General Conditions to Date 5% CM Fee to Date 34, 268.67 8,947.63 19, 711.81 985.59 14,556.86 7,962.04 34,268.67 8,947.63 100.00 100.00 Totals GRAND TOTAL 43,216.30 , 20,697.40 22,518.90 43,216.30 100.00 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 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. 10121OACD a :, Continuation Sheet Document G703TM -1992- Instructions GENERAL INFORMATION Purpose and Related Documents. AIA Document G7O3TM, Continuation Sheet, is to be used in conjunction with AIA Document G702TM' Application and Certificate for Payment, or AIA Document G732TM, 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 C. 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 I. 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 0702 or 0732 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 more Change Orders. Amounts remaining in dispute should be dealt with according to Section 7.3 of ALA Document A201 or Section 7.3 of AIA Document A232. The following is an erainple ofa Continuation Sheet for work in progress. Please note that dollar amounts sholln below are for illustrative proposes only. and are not intended to reflect actual construction costs. i1i® 111111111MIN ® _I_._ ITEM NO. DESCRIPTION OF WORK SCIIEDULED VALUE iriniMEMBEll MATERIALS I'RESI:N'rLY STORED a ( InDrxE) TOTAL COMI'LI:TI:D AND STORED TO DATE (G - C) BAL. ANCI TO FINIS!! (C - G) RI i1 IN CI (If variable rote) PROM PREVIOUS APPLICATION (D +E) TIIIS PERIOD 1 2 3 4 5 6 7 8 9 10 MOBILIZATION STUMP REMOVAL EARTH WORK LOWER RETAINING WALL CURBS A MISC. CONC. PAVING, UPPER DRIVE PAVING, LOWER DRIVE PAVERS BRICK WORK 5,000 5,000 15,000 10,000 5,000 20,000 20,000 , 20,000 5,000 5,000 5,000 10,000 0 0 0 0 0 0 0 0 5,000 5,000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0, o 0 5,000 5,000 15,000 5,000 0 0 0 10,000 0 100 100 100 50 0 0 0 50 0 0 0 0 5,000 5,000 20,000 20,000 10,000 5,000 11 GRAND TOTAL 105,000 20,000 10,000 10,000 40,000 65,000 AIA Document G703TM - 1992. Copyright © 1963, 1965, 966, 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 X Partial State of Indiana, County of Marion. SS: X Payment to Follow Matt Stump, being duly sworn, states that he is the Senior Project Manager 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. (PARTIAL WAIVER) that there is due from the owner the sum of Twenty Two Thousand Five Hundred Eighteen & 90/100 [ ] receipt of which is hereby acknowledged ; or Dollars ($ 22,518.90 [ 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 undersigned for said project, and within the scope of this affidavit and waiver. Keystone Construction Corporation By (Company) WITNESS MY HAND AND N Notary Public: (Authorized Represents roe) Title Senior Project Manager AL SEAL, this 25th day of March, 2011. State or Indiana County of Marion Printed Name: Andrea M. Rocll A :I A ra.ELL NOTARY PUBLIC SEAL STATE OF INDIANA MARION COUNTY MY COMMISSION EXPIRES: NOVEMBER 8, 2016 '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 K°9 5-740),,,,, C0.47,4-c,c717-c, ‘.7 L-9„,,,.. Purchase Order No. I/ 7 5 - , b12,,,,,,, 5 d/4,0,7,' .514 e Terms /ii(r,-747, /41 `4.2-- Date Due Invoice Date Invoice Number Description (or note attached invoice(s) or bill(s)) .. Amount 7/3//// /&/ac9e5 ige,.74,- , P 5e 7 3 ZY _S16 4 /6) / e i ' a :-.. .., 26 /63--ff.‘ Total z71 24' I hereby certify that the attached invoice(s), or bill(s), is (are) true with IC 5-11-10-1.6. 20 co ect nd I have audited same in accordance -Treasurer VOUCHER NO. WARRANT NO. �'�°J sT FYI Co -7Sfi -e, (- i o �a�.�✓. y7 5. /2,.0-7-7,/,,4,7,-o 57' -(7 1 's, 26, /6s8E ON ACCOUNT OF APPROPRIATION FOR x-02, PO# or DEPT. # *z INVOICE NO. ACCT #/TITLE AMOUNT /cJ /a8 6 2 / 7 //ay ALLOWED 20 IN SUM OF $ Board Members I hereby certify that the attached invoice(s), or 3 bill(s) is (are) true and correct and that the 22,5/?:W materials or services itemized thereon for which charge is made were ordered and received except Cost distribution ledger classification if claim paid motor vehicle highway fund 73 20// ICInatu r Execti ivePDirector Title Cannel Redevelopment Commission