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Home My WebLink AboutBROADY- CAMPBELL, INC.- 345- 8/11/2011 Broady-Campbell, Inc. Check: 345 2115 Dr. A.J. Brown Ave. Date: 8/11/2011 Indianapolis, IN 46202 Vendor: BROADY- Prior Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid 2-8 20,055.78 20,055.78 0.00 0.00 20,055.78 App 8 on Theater 2-9 44,078.45 44,078.45 0.00 0.00 44,078.45 App 9 on theater 64,134.23 64,134.23 0.00 0.00 64,134.23 345 8/11/2011 **********64,134.23 THE SUM OF SIXTY FOUR THOUSAND ONE HUNDRED THIRTY FOUR DOLLARS AND 23 CENTS * Broady-Campbell, Inc. 2115 Dr. A.J. Brown Ave. Indianapolis, IN 46202 Broady-Campbell, Inc. Check: 345 2115 Dr. A.J. Brown Ave. Date: 8/11/2011 Indianapolis, IN 46202 Vendor: BROADY- Prior Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid 2-8 20,055.78 20,055.78 0.00 0.00 20,055.78 App 8 on Theater 2-9 44,078.45 44,078.45 0.00 0.00 44,078.45 App 9 on theater 64,134.23 64,134.23 0.00 0.00 64,134.23 Application and Certificate for Payment TO OWNER: CARMEL THEATER DEVELOPMEPROJECT: VILLAGE ON THE GREEN 7-C APPLICATION NO: 8 Distribution to: CUST# CAR4 1 171 1 N.PENN ST. PERIOD TO: 05/31/2011 SUITE ZOO 12012 OWNER El CARMEL IN 46032 CONTRACT FOR: ARCHITECT ❑ FROM CONTRACTOR: BROADY-CAMPBELL,INC. VIA ARCHITECT: 06/23/2010 21 15 Dr.A.J.Brown Ave. CONTRACT DATE: CONTRACTOR ❑ PEDCOR DESIGN GROUP PROJECT NOS: Indianapolis,IN 46202 FIELD ❑ VILLAGE ON THE GREEN 7-C. JOB ii 210056 OTHER ❑ CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information Application is made for payment,as shown below,in connection with the Contract and belief the Work covered by this Application for Payment has been completed in accordance Continuation Sheet,is attached. with the Contract Documents, that all amounts have been paid by the Contractor for Work for 898,000.00 which previous Certificates for Payment were issued and payments received from the Owner, and 1.ORIGINAL CONTRACT SUM $ -16,131.00 that current payment shown herein is now due. 2. Net change by Change Orders $ 881,5000 CONTRAC R: Broady—Campbell, Inc. 3.CONTRACT SUM TO DATE(Line 1 ±2) $ 881,569.00 BY Date: 5-31-2011 4.TOTAL COMPLETED&STORED TO DATE(Column G on 603LS1).... $ State of Indiana 5. /MNAGE: County of Marion a. %of Completed Work 88,156.90 Subscribed and sworn to before (6Bbumn D+Eon 603LS 1) $ me this 31st day of May 2011 b. %of Stored Material 0.00 (Column F on 603LS1) $ Notary Public: IC J _' 88,15690 My Commission expires: 5-5-2016 Total Retainage(Lines 5a+5b or Total in Column I of 603LS I)... $ 6.TOTAL EARNED LESS RETAINAGE $ 793,412.10 ARCHITECT'S CERTIFICATE FOR PAYMENT (Line 4 Less Line 5 Total) 773,356.32 In accordance with the Contract Documents,based on on-site observations and the data comprising 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT $ 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 (Line 6 from prior Certificate) accordance with the Contract Documents, and the Contractor is entitled to payment of the 2444,-5 -8 7 8. CURRENT PAYMENT DUE $ AMOUNT CERTIFIED. � 9. BALANCE TO FINISH, INCLUDING RETAINAGE 88,156.90 AMOUNT CERTIFIED $ . oS3^_ -25 (Line 3 less Line 6) $ (Attach explanation if amount certified differs from the amount applied. Initial all figures on this Application and on the Continuation Sheet that a e changed to conform with the amount certified. CHANGE ORDER SUMMARY ADDI77�ii 77��S DEDi1CTIO�S .ABC f3.�:0.-tr",...i 7 1680. I9R00 oo �r I` /I/ Total changes approved in previous months by Owner $ 1 680 00 $ 0.00 By /�/ �—a!' Date: !/ / Total approved this Month $ 3,371.00 $ 19,805.00 TOTALS $ $ This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor -16 4z i nn named herein. Issuance,payment and acceptance of payment are without prejudice to any rights of v NET CHANGES by Change Order $ the Owner or Contractor under this Contract. �� REORDER FORM NO.604LS1 (� Continuation Sheet MA Document G703-1992 (Instructions on reverse side.) Page 1 of 3 AIA Document G702,APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 8 containing Contractor's signed Certification, is attached. APPLICATION DATE: 05/31/2011 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: 05/31/2011 ARCHITECT'S PROJECT NO: 12012 A B C D E F G H I WORK COMPLETED MATERIALS TOTAL BALANCE ITEM SCHEDULED PRESENTLY COMPLETED ova RETAINAGE DESCRIPTION OF WORK FROM PREVIOUS TO NO. VALUE STORED AND STORED (G _C) (IF VARIABLE) APPLICATION THIS PERIOD (NOT IN TO DATE FINISH RATE) (D + E) D OR E) (D+E+F) (C G) 01 104-4100 GENERAL 26,000.00 26,000.00 26,000.00 100.00 2,600.00 CONDITIONS 02 104-4101 BOND 8,000.00 8,000.00 8,000.00 100.00 800.00 03 104-4102 BLOCK LABOR 9,400.00 9,400.00 9,400.00 100.00 940.00 04 104-4103 BLOCK 2,700.00 2,700.00 2,700.00 100.00 270.00 MATERIAL 05 104-4104 EAST FACE 121,430.00 121,430.00 121,430.00 100.00 12,143.00 BRICK LABOR 06 104-4105 EAST BRICK 56,400.00 56,400.00 56,400.00 100.00 5,640.00 MATERIAL 07 104-4106 SOUTH FACE 104,560.00 92,012.80 12,547.20 104,560.00 100.00 10,456.00 BRICK 08 104-4107 SOUTH BRICK 48,600.00 48,600.00 48,600.00 100.00 4,860.00 MATERIAL 09 104-4108 WEST FACE 115,100.00 107,043.00 8,057.00 115,100.00 100.00 11,510.00 BRICK LABOR 10 104-4109 WEST BRICK 53,500.00 53,500.00 53,500.00 100.00 5,350.00 MATERIAL 11 104-4110 WEST 6,500.00 6,500.00 6,500.00 100.00 650.00 LIMESTONE LABOR 12 104-4111 WEST 24,500.00 24,500.00 24,500.00 100.00 2,450.00 LIMESTONE MATERIAL 13 104-4112 WEST 14,800.00 14,800.00 14,800.00 100.00 1,480.00 PAGE TOTALS : 591,490.00 570,885.80 20,604.20 .00 591,490.00 .00 59,149.00 G703-1992 Continuation Sheet AIA Document G703-1992 (Instructions on reverse side.) Page 2 of 3 AIA Document G702,APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 8 containing Contractor's signed Certification, is attached. APPLICATION DATE: 05/31/2011 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: 05/31/2011 ARCHITECT'S PROJECT NO: 12012 A B C D E F G H I WORK COMPLETED MATERIALS TOTAL BALANCE ITEM SCHEDULED PRESENTLY COMPLETED ova RETAINAGE DESCRIPTION OF WORK FROM PREVIOUS TO NO. VALUE STORED AND STORED (G -=C) (IF VARIABLE) APPLICATION THIS PERIOD (NOT IN TO DATE FINISH RATE) (D + E) D OR E) (D+E+F) (C G) GRANITE LABOR - 14 104-4113 WEST 60,720.00 60,720.00 60,720.00 100.00 6,072.00 GRANITE MATERIAL 15 104-41 14 NORTI-I FACE 80,550.00 80,550.00 80,550.00 100.00 8,055.00 BRICK LABOR 16 104-4115 NORTH BRICK 37,500.00 37,500.00 37,500.00 100.00 3,750.00 MATERIAL 17 104-4116 NORTH 10,900.00 10,900.00 10,900.00 100.00 1,090.00 LIMESTONE LABOR 18 104-4117 NORTH 41,500.00 41,500.00 41,500.00 1 00.00 4,150.00 LIMESTONE MATERIAL 19 104-4118 NORTH 9,860.00 9,860.00 9,860.00 100.00 986.00 GRANITE LABOR 20 104-41 19 NORTH 40,480.00 40,480.00 40,480.00 100.00 4,048.00 GRANITE MATERIAL 21 104-4120 ALLOWANCE 25,000.00 25,000.00 25,000.00 100.00 2,500.00 22 104-4121 CO# 52 TAX -19,805.00 -19,805.00 -19,805.00 100.00 -1,980.50 EXEMPTION 23 104-4122: CO.I 15- 480.00 480.00 480.00 100.00 48.00 29 24 104-4123:C0.106- 24.00 24.00 24.00 100.00 2.40 ASI.022 25 104-4124 C0.130 1,190.00 1,190.00 1,190.00 100.00 119.00 OVERTIME HOURS PAGE TOTALS : 288,399.00 288,399.00 .00 .00 288,399.00 .00 28,839.90 G703-1992 Continuation Sheet MA Document G703-1992 (Instructions on reverse side.) Page 3 of 3 .AIA Document G702,APPLICATION AND CERTIFICATE FOR PAYMENT. APPLICATION NO.: 8 containing Contractor's signed Certification, is attached. APPLICATION DATE: 05/31/2011 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: 05/31/2011 ARCHITECT'S PROJECT NO: 12012 A B C D E F G H I WORK COMPLETED MATERIALS TOTAL ITEM SCHEDULED PRESENTLY COMPLETED oho BALANCE RETAINAGE DESCRIPTION OF WORK FROM PREVIOUS _ TO (IF VARIABLE) (G C) NO. VALUE STORED AND STORED FINISH APPLICATION THIS PERIOD (D + E) (NOT IN TO DATE (C-G) RATE) D OR E) (D+E+F) 26 184-4125.00145 1,36-0.00 1,360.0'0 1,360.00 100.00 1.36.00 PR.46 27 104-4126C0.148 320.00 320.00 320.00 100.00 32.00 PR.053 JOB TOTALS : 881,569.00 859,284.80 22,284.20 .00 881,569.00 100 .00 88,156.90 G703-1992 CONTINUATION SHEET AIA DOCUMENTG703 PAGE OF PAGES A1A Document G702,APPLICATION AND CERTIFICATION FOR PAYMENT,containing APPLICATION NO: 8 Contractor's signed certification is attached. APPLICATION DATE: 05/31/11 In tabulations below,amounts are stated to the nearest dollar. PERIOD TO: Ue Column I on Contracts where variable retainage for line items may apply. ARCHITECTS PROJECT NO: 12012 A B C D I E F G H I ITEM DESCRIPTION OF WORK SCHEDULED WORK COMPLETED MATERIALS TOTAL % BALANCE RETAINAGE NO. VALUE FROM PREVIOUS THIS PERIOD PRESENTLY COMPLETED (G=C) TO FINISH (IF VARIABLE APPLICATION STORED AND STORED (C-G) RATE) (D+E) (NOT IN TO DATE D OR E) (D+E+F) 1 CO#63 BRICK ANCHORS $10,039.00 $10,039.00 $0.00 $10,039.00 100.00% $0.00 2 CO#58 PR.08 $9,792.00 $9,792.00 $0.00 $9,792.00 100.00% $0.00 3 CO#64 ASI.017 $2,540.00 $2,540.00 $0.00 $2,540.00 100.00% $0.00 4 CO#72 PR.009 $1,338.00 $1,338.00 $0.00 $1,338.00 100.00% $0.00 5 CO# 106-ASI.022 $791.00 $791.00 $0.00 $791.00 100.00% $0.00 6 CO#93 PR.025 $500.00 $500.00 $0.00 $500.00 100.00% $0.00 $0.00 $0.00 GRAND TOTALS $25,000.00 $25,000.00 $0.00 $0.00 $25,000.00 100% $0.00 $0.00 Users may obtain validation of this document by requesting of the license a completed AIA Document D401 -Certification of Document's Authenticity AIA DOCUMENT G703•CONTINUATION SHEET FOR G702•1992 EDITION•AIA•c1992 THE AMERICAN INSTITUTE OF ARCHITECTS,1735 NEW YORK AVENUE.N.W.WASHINGTON,D.C. 20006-5232 G703-1992 PRIME CONTRACTOR'S SWORN STATEMENT OF INDEBTNESS &WAIVER OF LIEN STATE OF Indiana COUNTY OF Hamilton Scott Broady Being duly sworn upon his/her oath disposes and says that: 1. He/she is President (inserting sole proprietor, partner or corporate office held, as the case maybe), of Broady-Campbell, Inc. hereafter called the "Prime Contractor". He/she is over the age of twenty-one. He/she is authorized to make this affidavit on behalf of Prime Contractor. 2. Prime Contractor is the _Masonry_ Prime Contractor for the construction of the development known as VILLAGE ON THE GREEN — PARCEL 7C1 — THEATER BUILDING located in CARMEL (City), INDIANA (state), hereafter referred to as the "Development", pursuant to the contract between the Prime Contractor and CARMEL THEATER DEVELOPMENT CORPORATION, LLC., the Owner. 3. This affidavit is made for the express purpose of inducing and CARMEL THEATER DEVELOPMENT CORPORATION, LLC., to make payment to Prime Contractor of the invoice submitted herewith for labor and materials furnished pursuant to said Contractor. Upon receipt of said payment the Prime Contractor hereby waives any lien rights to which Prime Contractor is entitled for labor or materials furnished for the development to the date hereof. 4. Listed below are all suppliers or other persons who either has furnished or might furnish the Prime Contractor with materials, appliances, machinery, fixtures or furnishing placed upon or installed on the development. Mark (X) in the appropriate column for EACH supplier listed. Place an (X) in column: 1) If a waiver of lien by supplier conditioned by payment of a specified amount is attached hereto. (In this case also show the amount owed the supplier). 2.) If a FULL (final) lien release has been signed and delivered to the Owner. 3.) If the initial delivery has not been made. Supplier List(Add list if necessary 1. Amount Owed < 3 Architectural Brick & I lle /,528.UU X #1 and 2 correspond to the same numbered choices on the waiver format. CARMEL THEATER DEVELOPMENT CORPORATION, LLC.is hereby authorized to make payment to each such unpaid creditor either directly or by check jointly payable to Prime Contractor and such creditor, as CARMEL THEATER DEVELOPMENT CORPORATION, LLC. shall determine. 5. There are no bills, charges, costs or expenses for labor or material which could now or hereafter result in lien being filed against the Development or a claim being asserted against the Owner except the persons or businesses named in Paragraph 4 above. IN WITNESS WHERE OF, affiant has signed this document on behalf of the Prime Contractor this _31st_ day of _May_, 2011_ (Authorized Representative Prime Contractor, Title) County of Marion State of Indiana Subscribed and sworn to before me, a Notary Public in and for said County and State, This 31st Day of May , 2011 (Notary Public) Denise E. Broady (Printed Name) My Commission Expires: 5-5-2016 NOTARY SEAL MUST APPEAR ON THIS FORM. 1 Application and Certificate for Payment TO OWNER: CARMEL THEATER DEVELOPMIPROJECT: VILLAGE ON THE GREEN7-C APPLICATION NO: 9 Distribution to: CUST Y CAR4 11711 N.PENN ST. PERIOD TO: 05/31/201 I OWNER ❑ SUITE 200 12012 CARMEL IN 46032 CONTRACT FOR: ARCHITECT ❑ FROM CONTRACTOR: BROADY-CAMPBELL,INC. VIA ARCHITECT: CONTRACT DATE: 06/23/2010 2115 Dr.A.J.Brown Ave. CONTRACTOR ❑ PEDCOR DESIGN GROUP PROJECT NOS: FIELD ❑ Indianapolis,IN 46202 VILLAGE ON THE GREEN 7-C JOB# 210056 OTHER ❑ CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information Application is made for payment,as shown below,in connection with the Contract and belief the Work covered by this Application for Payment has been completed in accordance Continuation Sheet,is attached. with the Contract Documents, that all amounts have been paid by the Contractor for Work for 898,000.00 which previous Certificates for Payment were issued and payments received from the Owner, and 1.ORIGINAL CONTRACT SUM $ 16,131.00 that current payment shown herein is now due. 2. Net change by Change Orders $ 081,569.00 CONTRA Broad —Campbell, Inc. 3. CONTRACT SUM TO DATE (Line 1 ±2) $ 8'81,569.00 By. Date: 5-31-2011 4.TOTAL COMPLETED&STORED TO DATE(Column G on 603LS1).... $ State of Indiana 5. Rad4INAGE: County of Marion a. %of Completed Work 44,078.45 Subscribed and sworn to before (c. umn D+Eon 603LS1) - $ me this 31st day of May 3011 b. %of Stored Material 0.00 (Column F on 603LS1) $ Notary Public: E____:V 44,078.45 My Commission expires: 5-5-2016 Total Retainage(Lines 5a+5b or Total in Column I of 603LS1) ... $ 6.TOTAL EARNED LESS RETAINAGE $ 837,490 55 ARCHITECT'S CERTIFICATE FOR PAYMENT (Line 4 Less Line 5 Total) 793,412 10 In accordance with the Contract Documents,based on on-site observations and the data comprising 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT $ 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 (Line 6 from prior Certificate) accordance with the Contract Documents, and the Contractor is entitled to payment of the 8. CURRENT PAYMENT DUE $ --1 AMOUNT CERTIFIED. 9. BALANCE TO FINISH, INCLUDING RETAINAGE 44,078.45 AMOUNT CERTIFIED $ `ref o i i Lf } (Line 3 less Line 6) $ (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. CHANGE ORDER SUMMARY ADDITI NS DEDUCTIONS ARGHHiE �Z✓ " "'��' 3,3700 19,805.00 671/.1 Total changes approved in previous months by Owner $ 0 00 $ -0.00 By �� Date: Total approved this Month $ $ 3,374.00 19,805 00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor TOTALS $ -161a34n0 $ 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. G REORDER FORM NO.604LS1 6P Continuation Sheet AAA Document G703-1992 (Instructions on reverse side.) Page 1 of 3 AIA Document G702,APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 9 containing Contractor's signed Certification, is attached. APPLICATION DATE: 05/31/2011 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: 05/31/2011 ARCHITECT'S PROJECT NO: 12012 A B C D E F G H I WORK COMPLETED MATERIALS TOTAL ITEM SCHEDULED PRESENTLY COMPLETED ova BALANCE RETAINAGE TO NO. DESCRIPTION OF WORK VALUE FROM PREVIOUS STORED AND STORED APPLICATION THIS PERIOD (G _C) FINISH ([F VARIABLE) (NOT IN TO DATE RATE) (D + E) D OR E) (D+E+F) (C G) 01 104-4100 GENERAL 26,000.00 26,000.00 26,000.00 100.00 1,300.00 CONDITIONS 02 104-4101 BOND 8,000.00 8,000.00 8,000.00 100.00 400.00 03 104-4102 BLOCK LABOR 9,400.00 9,400.00 9,400.00 100.00 470.00 04 104-4103 BLOCK 2,700.00 2,700.00 2,700.00 100.00 135.00 MATERIAL 05 104-4104 EAST FACE 121,430.00 121,430.00 121,430.00 100.00 6,071.50 BRICK LABOR 06 104-4105 EAST BRICK 56,400.00 56,400.00 56,400.00 100.00 2,820.00 MATERIAL 07 104-4106 SOUTH FACE 104,560.00 104,560.00 104,560.00 100.00 5,228.00 BRICK 08 104-4107 SOUTH BRICK 48,600.00 48,600.00 48,600.00 100.00 2,430.00 MATERIAL 09 104-4108 WEST FACE 115,100.00 115,100.00 115,100.00 100.00 5,755.00 BRICK LABOR 10 104-4109 WEST BRICK 53,500.00 53,500.00 53,500.00 100.00 2,675.00 MATERIAL 11 104-4110 WEST 6,500.00 6,500.00 6,500.00 100.00 325.00 LIMESTONE LABOR 12 104-4111 WEST 24,500.00 24,500.00 24,500.00 100.00 1,225.00 LIMESTONE MATERIAL 13 104-4112 WEST 14,800.00 14,800.00 14,800.00 100.00 740.00 PAGE TOTALS : 591,490.00 591,490.00 .00 .00 591,490.00 .00 29,574.50 G703-1992 Continuation Sheet MA Document 6703-1992 (Instructions on reverse side.) Page 2 of 3 AIA Document G702,APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 9 containing Contractor's signed Certification, is attached. APPLICATION DATE: 05/31/2011 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: 05/31/2011 ARCHITECTS PROJECT NO: 12012 A B C D E F G H I WORK COMPLETED MATERIALS TOTAL ITEM SCHEDULED PRESENTLY COMPLETED % BALANCE RETAINAGE NO. DESCRIPTION OF WORK VALUE FROM PREVIOUS STORED AND STORED APPLICATION THIS PERIOD (G _ C) FINI H CIF VARIABLE) (NOT IN TO DATE RATE) (D+E) D OR E) (D+E+F) (C G) GRANITE LABOR 14 104-4113 WEST 60,720.00 60,720.00 60,720.00 100.00 3,036.00 GRANITE MATERIAL 15 104-4114 NORTH FACE 80,550.00 80,550.00 80,550.00 100.00 4,027.50 BRICK LABOR 16 104-4115 NORTH BRICK 37,500.00 37,500.00 37,500.00 100.00 1,875.00 MATERIAL 17 104-4116 NORTH 10,900.00 10,900.00 10,900.00 100.00 545.00 LIMESTONE LABOR 18 104-4117 NORTH . 41,500.00 41,500.00 41,500.00 100.00 2,075.00 LIMESTONE MATERIAL 19 104-4118 NORTH 9,860.00 9,860.00 9,860.00 100.00 493.00 GRANITE LABOR 20 104-4119 NORTH 40,480.00 40,480.00 40,480.00 100.00 2,024.00 GRANITE MATERIAL 21 104-4120 ALLOWANCE 25,000.00 25,000.00 25,000.00 100.00 1,250.00 22 104-4121 CO# 52 TAX -19,805.00 -19,805.00 -19,805.00 100.00 -990.25 EXEMPTION 23 104-4122: C0.115- 480.00 480.00 480.00 100.00 24.00 29 24 104-4123:C0.106- 24.00 24.00 24.00 100.00 1.20 ASI.022 25 104-4124 C0.130 1,190.00 1,190.00 1,190.00 100.00 59.50 OVERTIME HOURS PAGE TOTALS : 288,399.00 288,399.00 .00 .00 288,399.00 .00 14,419.95 G703-1992 Continuation Sheet AM Document G703-1992 (Instructions on reverse side.) Page 3 of 3 AIA Document G702,APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 9 containing Contractor's signed Certification, is attached. APPLICATION DATE: 05/31/2011 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: 05/31/2011 ARCHITECT'S PROJECT NO: 12012 A B C D E F G H I WORK COMPLETED MATERIALS TOTAL BALANCE ITEM SCHEDULED PRESENTLY COMPLETED % RETAINAGE NO. DESCRIPTION OF WORK VALUE FROM PREVIOUS STORED AND STORED TO APPLICATION THIS PERIOD (NOT IN TO DATE (G C) FINISH (IF VARIABLE) (D + E) D OR E) (D+E+F) (C G) 2G 104-4125.00145 1,3-60.00 1,360-00 1,360.00 100.00 68.00 PR.46 27 104-4126C0.148 320.00 320.00 320.00 100.00 16.00 PR.053 JOB TOTALS : 881,569.00 881,569.00 .00 .00 881,569.00 100 .00 44,078.45 G703-1992 1 CONTINUATION SHEET AIA DOCUMENTG703 PAGE OF PAGES ALA Document G702,APPLICATION AND CERTIFICATION FOR PAYMENT,containing APPLICATION NO: 9 Contractor's signed certification is attached. APPLICATION DATE: 05/31/11 In tabulations below,amounts are stated to the nearest dollar. PERIOD TO: Use Column Ion Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO: 12012 A B C D I E F G H I ITEM DESCRIPTION OF WORK SCHEDULED WORK COMPLETED MATERIALS TOTAL % BALANCE RETAINAGE NO. VALUE FROM PREVIOUS THIS PERIOD PRESENTLY COMPLETED (G_C) TO FINISH (IF VARIABLE APPLICATION STORED AND STORED (C-G) RATE) (D+E) (NOT IN TO DATE D OR E) (D+E+F) 1 CO#63 BRICK ANCHORS $10,039.00 $10,039.00 $0.00 $10,039.00 100.00% $0.00 2 CO#58 PR.08 $9,792.00 $9,792.00 $0.00 $9,792.00 100.00% $0.00 3 CO#64 ASI.017 $2,540.00 $2,540.00 $0.00 $2,540.00 100.00% $0.00 4 CO#72 PR.009 $1,338.00 $1,338.00 $0.00 $1,338.00 100.00% $0.00 5 CO# 106-A$1.022 $791.00 $791.00 $0.00 $791.00 100.00% $0.00 6 CO#93 PR.025 $500.00 $500.00 $0.00 $500.00 100.00% $0.00 $0.00 $0.00 GRAND TOTALS $25,000.00 $25,000.00 $0.00 $0.00 $25,000.00 100% $0.00 $0.00 Users may obtain validation of this document by requesting of the license a completed AIA Document D401 -Certification of Document's Authenticity AIA DOCUMENT G703•CONTINUATION SHEET FOR G702•1992 EDITION-AIA.51992 THE AMERICAN INSTITUTE OF ARCHITECTS,1735 NEW YORK AVENUE,N.W.WASHINGTON,D.C. 20006-5232 G703-1992