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HomeMy WebLinkAboutCERTIFIED FLOORCOVERING SERVIC- 344- 8/11/2012 Certified Floorcovering Servic Check: 344 5150 W 84th Street Date: 8/11/2011 Indianapolis, IN 46268 Vendor: CERTIFII Prior Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid 2-2 59,344.92 59,344.92 0.00 0.00 59,344.92 App 2 on theater 59,344.92 59,344.92 0.00 0.00 59,344.92 344 8/11/2011 **********59,344.92 THE SUM OF FIFTY NINE THOUSAND THREE HUNDRED FORTY FOUR DOLLARS AND 92 CENTS Certified Floorcovering Servic 5150 W 84th Street Indianapolis, IN 46268 Certified Floorcovering Servic Check: 344 5150 W 84th Street Date: 8/11/2011 Indianapolis, IN 46268 Vendor: CERTIFI1 Prior Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid 2-2 59,344.92 59,344.92 0.00 0.00 59,344.92 App 2 on theater 59,344.92 59,344.92 0.00 0.00 59,344.92 APPLICATION AND CERTIFICATE FOR PAYMENT PAGE ONE OF Job#106603 AIA DOCUMENT G702/CMa To Contr: Project: Villiage on the Green Parcel 7-C-1 Carmel Theater Development,LLC 3 Center Green APPLICATION NO.: 2 Distribution to: 1016 3rd Ave.,SW,Suite 200 Carmel, Indiana 46032 Carmel,IN 46032 PERIOD TO: 5/3012011 OWNER X CONSTRUCTIO MGR From Contractor: PROJECT NOS.: 12012 ARCHITECT CERTIFIED FLOORCOVERING SERVICES, INC. Certified Floorcovering#: 106602 CONTRACTOR 5150 W.84TH STREET VIA CONSTRUCTION MANAGER: INDIANAPOLIS. IN 46268 VIA ARCHITECT: Contract For:FLOOR COVERING Contract Date#: 01/26/11 Pencil due 18th,org.21,bill thru EOM CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the :t-st of the Cott MILIER' E Application is made for payment as shown below,in connection with the Contract information and belief the Work covered by this `.plication for ritranrillimbegaas Continuation Sheet,AIA Document G703 attached. completed in accordance with the contract docu gents,that all arayiethue on paid by the Contractor for work for which previous certif, :tes 1.Original Contract Sum S141,997.00 payments received from the Owner and that cur , . n-At shown is a eIFI no • 20110 9 4 2.Net Change by Change Orders 0.00 Contractor: Certified Floorcovering Services, Inc. arol S. illi- Pr si erjt 3.Contract Sum To Date 141,997.00 By: / �4 DATE: .23-// State of: Indiana Coun y Of: Marion 4.Total Completed&Stored to Date 75,318.80 Subscribed and sworn to be ore me this day of ,2011 Notary Public:Rhonda R.Goff .2• _ 5.Retainage My Commission Expires: 05/04/2019 a. 10.00%of Completed Work $7,531.88 ARCHITECT'S CERTIFICATION In accordance with the contract documents, based on on-site observa/ions and The data comprising this application, :he Construction Manager and Architect certify to the Owner that Total Retainage: 7,531.88 to the best of their knowledge,information and belief the Work has progressed as incicate,d,the quality of the work is in accordance with the Contract Documents,and tr..Contractor 6.Total Earned Less Retainage 67,786.92 is entitled to payment of the AMOUNT CERTIFIED 7.Less Previous Certificates for Payment 8,442.00 AMOUNT CERTIFIED 3-13 4/6-4 f 8.Current Payment Due $59,344.92 (Attach explanation if amount certified differs from the amount applied for. Initial all figures on this application and on the continuation sheet that are 9.Balance Due to Finish,Including Retainage $74,210.08 changed to conform to the amount certified.) CONSTRUCTION MANAGER t'Cli Change Order Summary Additions Deductions By: Date: Total changes approved in dU.J . r\PP previous months by owner - - EC� / / Total approved this month(November-32) By: --��-/( Date: C// /I1 Totals - - Net change by Change Order: - This certificate is not negotiable The amount certified is payable only to the Contractor named herein.Issuance,payment&acceptance of payment are without prejudice to any rights of the owner or contractor under this contract. APPLICATION AND CERTIFICATE FOR PAYMENT PAGE ONE OF Job#106603 AIA DOCUMENT G702/CMa To Contr: Project: Villiage on the Green Parcel 7-C-1 Carmel Theater Development,LLC 3 Center Green APPLICATION NO.: 2 Distribution to: 1016 3rd Ave.,SW.Suite 200 Carmel, Indiana 46032 Carmel, IN 46032 PERIOD TO: 5/30/2011 OWNER X CONSTRUCTIO MGR From Contractor: PROJECT NOS.: 12012 ARCHITECT CERTIFIED FLOORCOVERING SERVICES, INC. Certified Floorcovering#: 106602 CONTRACTOR 5150 W.84TH STREET VIA CONSTRUCTION MANAGER: INDIANAPOLIS. IN 46268 VIA ARCHITECT: Contract For: FLOOR COVERING Contract Date#: 01/26/11 APPLICATION FOR PAYMENT-CONTINUATION SHEET Job#106603 A B C D E F G H I ITEM SCHEDULED PREVIOUS COMPLETED STORED TOTAL CP& % BALANCE TO RETAINAGE NO. DESCRIPTION OF WORK VALUE WORK THIS PERIOD MATERIALS STORED TO DATE (G/C) FINISH(C-G) 10.00% 0.00 0.00 0.00 0.00 0.00 0.00% 0.00 0.00 109-1000 Submittals/Closeout 2.000.00 900.00 0.00 0.00 900.00 45.00% 1,100.00 90.00 0.00 0.00 0.00 0.00 0.00 0.00% 0.00 0.00 109-1001 Marble Showers 16,000.00 8,480.00 0.00 0.00 8,480.00 53.00% 7,520.00 848.00 109-1002 Labor 4,000.00 0.00 0.00 0.00 0.00 0.00% 4,000.00 0.00 109-1003 093000-Tiling 27,972.00 0.00 0.00 11,188.80 11,188.80 40.00% 16,783.20 1,118.88 109-1004 Labor 11,000.00 0.00 0.00 0.00 0.00 0.00% 11,000.00 0.00 109-1005 93123-Glass Mosaic 2.500.00 0.00 0.00 2,500.00 2,500.00 100.00% 0.00 250.00 109-1006 Labor 400.00 0.00 0.00 0.00 0.00 0.00% 400.00 0.00 109-1007 096513-Resilient Base&Access. 2.600.00 0.00 0.00 2,600.00 2,600.00 100.00% 0.00 260.00 109-1008 Labor 2,000.00 0.00 0.00 0.00 0.00 0.00% 2,000.00 0.00 109-1009 096519-Resilient Tile 400.00 0.00 0.00 400.00 400.00 100.00% 0.00 40.00 109-1010 Labor 225.00 0.00 0.00 0.00 0.00 0.00% 225.00 0.00 109-1011 096813-Tile Carpet 950.00 0.00 0.00 950.00 950.00 100.00% 0.00 95.00 109-1012 Labor 100.00 0.00 0.00 0.00 0.00 0.00% 100.00 0.00 109-1013 096816-Sheet Carpet 48,300.00 0.00 0.00 48,300.00 48,300.00 100.00% 0.00 4,830.00 109-1014 Labor 8,550.00 0 00 0.00 0.00 0.00 0.00% 8,550.00 0.00 109-1015 Allowance(see allowance usage spreadsheet) 15,000.00 0.00 0.00 0.00 0.00 0.00% 15,000.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00% 0.00 0.00 TOTALS: $141,997.00 $9,380.00 $0.00 $65,938.80 $75,318.80 35.44% $66,678.20 $7,531.88 PRIME CONTRACTOR'S SWORN STATEMENT OF INDEBTNESS &WAIVER OF LIEN STATE OF Indiana COUNTY OF Hamilton Carol S. Mill Being duly sworn upon his/her oath disposes and says that: 1. He/she is Vice President (inserting sole proprietor, partner or corporate office held, as the case maybe), of Certified Floorcovering Service, 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 Flooring 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 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 ha_s 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 2 3 Ohio Valley Flooring x$2,33U.UU J& J )($1,/299.94 Classic Stone tbd Bentley Prince Street tbd Louisville I ile tbd Bigelow tbd Blueridge tbd Natural Stone tbd EJ Welch tbd #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/Y( day of May , 20_11 11124 te4 (Authorized`Re resentative or 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 v2 q y Day of Ma , 2n11 Rtd jr.._..r7.�.i.....;x,:,-;fic.,z.i,,.itv':acti•;.�r.�:r4r •�I.• 'Y. � OP,±DA 6iE�& % � 4— ,. r Notary Pelee o 001 State Of Indiana My Commission Expires May 4,2019 1 • (Notary Public) Rhonda Goff (Printed Name) My Commission Expires: NOTARY SEAL MUST APPEAR ON THIS FORM. • 2 WAIVER OF MECHANIC'S LiEN RIGHT BY SUPPLIER WHERE AS, the undersigned furnished rtraterials and/or services to the insured development known as \ki 6 tl,rr+1rR. located at , in the city of , county of state of INDIANA. WHERE AS, the undersigned desires to waive, release and quit-claim to Owner, all lien rights, including the right to file a notice of Mechanic's Lien or hereafter a Mechanic's lien upon the above described real estate to the extent for which the undersigned has received payment arid to the extent permitted by the laws of the state of INDIANA ..{ •if. >' li.'.r.,I✓ U�1 .k, ,. a f L bi, `(-(.:r it NOW,THEREFORE, in consideration of the sum of 1"`-Ii --li' i Dollars(S Li ��- ?I)and other valuable consideration. receipt of which hereby acknowledged, the undersimied has hereby waived, released and quit-claim to Owner; (indicated either(1) or(2)). in / 1. All lien ri� hts as described above which it has or could have under the laws of the state if � ;/ INDIANA to the date hereof for or on account of materials, appliances, machinery, fixtures, or furnishings, placed upon or installed on the above-described real estate. This waiver is effective upon receipt of 7.*'t`N?;,‘✓^:`ii �. i4',. : .,)i.:=/'ih/111/`/lOO Dollars($ 532„ 33). 77,.t, 5 3/i,,,, 2. All lien rights as described above which it has or could have under the laws of the state if INDIANA to the date hereof for or on account of materials, appliances, machinery, fixtures, or furnishings, placed upon or installed on the above-described real estate. This shall constitute a full and final waiver of the undersigned's rights to a Mechanic's Lien on the above-described real estate. Fl DATED This/ day of A,' / . 20101. (Signature) i , (Name of Supplier) k." it 1//'Iva.?K,:i Certified Flourcovering Services, inc. (Name of Subcontractor) (Revised 10;2000 Signature) 1 tACO D CERTIFICATE OF LIABILITY INSURANCE 5i18i2ollrr) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Suzi Q. McGuire Pillar Group Risk Management, Inc. lac No.Ext): (317)853-3500 853-3500 (a/c,No):(317)853-3501 301 Pennsylvania Parkway ADOISS:smcguire @pillargrp.com Suite 100 PRODUCER D0017221 CSJSTOMER ID#, Indianapolis IN 46280 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A Amerisure Companies INSURER B: Certified Floorcovering Services, Inc. INSURERC: 5150 West 84th Street INSURERD: INSURER E: Indianapolis IN 46268 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF POLICY EXP (MMIDD/YYYYL(MMIDD/YYYY) LIMITS A GENERAL LIABILITY CPP2064396 9/9/2010 9/9/2011 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 3CI COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 100,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000 PERSONAL8ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X JEC7 LOC $ A AUTOMOBILE LIABILITY CA2064395 9/9/2010 9/9/2011 COMBINED SINGLE LIMIT $ 1,000,000 X ANY AUTO (Ea accident) BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ $ A X UMBRELLA LIAB X OCCUR CU2064398 9/9/2010 9/9/2011 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DEDUCTIBLE $ RETENTION $ $ - A WORKERS COMPENSATION WC2064397 9/9/2010 9/9/2011 X WCSTATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS FR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 A Contractors Equi/EDP CPP2064396 9/9/2010 9/9/2011 $31,099 Equip/$35,800 EDP A Installation Floater CPP2064396 9/9/2010 9/9/2011 $400,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: Village of the Green See Notes: Revised from 3/10/11 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Carmel Theater Development Corporation, L 11711 North Pennsylvania St. AUTHORIZED REPRESENTATIVE Suite 200 Carmel, IN 46032 Daniel Touw/JMH - ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD COMMENTS/REMARKS REI Construction, LLC, Signature Construction, LLC, Pedcor Design Group, LLC, McComas Engineers, Inc. , L'Acquis Consulting Engineers, CSO, and their directors, officers, employees, agents and representatives are added as additional insureds on the General Liability but only with respect to liability arising out of the work performed by or on behalf of the named insured for the above project and in accordance with the written contract. A Waiver of Subrogation is added in favor of the additional insureds shown above on the General Liability policy. General Liability policy is Primary and Noncontributory in favor of the above additional insureds. The Producer shown on the ACORD 25 will provide the Certificate Holder 60 days written notice of cancellation if cancellation of the policy(ies) shown on the Certificate is initiated by the Insurance Company(ies) for reasons other than non-payment of premium. Installation Floater includes coverage for Material Stored at 5150 West 84th Street Indianapolis, IN valued at approximately $65, 938.80 OFREMARK COPYRIGHT 2000, AMS SERVICES INC. OHIO VALLEY FLOORING Ohio PO BOK 14360A SHIPPER valley CINCINNATI, OHIO 45250 (513) 561-3399 ORMit Flooring 800-955-7228 110M: AIP TO: , FL. ".3P . . . _ . . _ DFR OT- -T'f.VYK FFP171),CM17.:1:- I II ,.. . . _ . r.JRIP:N/PX LP/IHri/L/ - ------ '1": 5..3434 PA:3 p .0 m'v, • ; ;.. 7 E !,7 T r "3. •r..; 7'2 PE . • • - • • • • • .. . 1_ • • 11".1wis .r y If IEFICHANIME REM},BY • " • •• mERC}4.4NOISE MAY NOT BE H .•: EEP THIS COPY As PROOF OF C,EustERY. RETURNED WITHOUT P OFr AUTBORIZATIOH. 'Oup siGNATURE ACKNOvA.CiaGE'S RECEIPT OF APN)vc mspc,HANDISE GOoD coNDITION. • . „ . . . . . . . _ CZTY OHIO VALLEY FLOORING Ohio PO BOX 14360A - SHIPPER valley CINCINNATI, OHIO 45250 • '. :.,:;:.=:,-,,.. 0.1nekt . (513)561-3399 . Flooring 800-955-7228 . ' • •• - ' .....% . . , .. . .... FL .-. . •-.:••.1::: : ):1 ?..;1l s!.:: ;T: .-1 '' ''..7I' fi i:'--Ci :4 ::JFJ.:•:%i.T •-11. '•,. '::::1 '.'„:.) :.',.4.TH Zi..II . .. .1.1.;..!..1'(.1:•.sn,r!..i.....1.!:; ,'7.S :: '.; PiriT:!,..,-..:'....,..._I;:i '. IN ,•,1.:Y26'.5 .1.: DI ''..;:=4:.:::_i IH ,c.::,:•Ys':; ......... YT::* - -r . ;1 , a . --- ----- 4;: cN7t- CUT P . D.41./.. -- ---11.:::51-i------ --D :tER • — • . _ _ . .• • . . F ... :. . ,..:: . .. .: : . h h •: .G' ' 1 f *:: !:' : . . •...,:::'.-:•:'::: s....'....:' • : !: I.i..1:.;!!!'.- ',...". f. ...;-.! .!. I:,i l..! T. !...f:!.:.'G.'I„. 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Ii.LE 1/E; 1 'POP :1.2 0 -..-oli 064t; ' . : . • :..-. .:•.., .. • • — — _ — I • :k.-r :-,,: :491",^. . - :•;:/ il..;•:; 1, ,; :i!t ! Ili : Z:ril.'-67 --Y:';'2. .,•'"' • , ..•• .- ,,...:.! Py : ,: .!,•:.:.,1 1:\, : . . • • • RERCHANIME RECD.BY ' •••• .; ' -"'"' ..>1:, ,fe, r/.L:f..,4`..-' MERCHANDISE MAY NOT OE !:%■';' <EEP THIS COPY AS PROOF OF DELIVEHY. RETURNED WITHOUT PMORAUTHOstaAnom. I... YOUR SIGNATURE ACKNOWLEDGES HECEIPT OF ABOVE MERCHANDISE IN GOOD CONDITION. . . . INVOICE 4:*-0A"t lf-C 1 1 P ELL® INC. , MASONRY CONTRACTORS 2115 ANDREW J. BROWN AVE. • INDIANAPOLIS, INDIANA 46202 21758 ph. (317) 925-4261 fax (317) 925-4263 Signature Const. LLC. Date 05-31-2011 One Pedcor Square TO: 720 3rd Avenue SW 210056 Carmel, IN 46032 Job No. P.O. No. RE: Village on the Green 7-C ESTIMATE NO: 9 Labor, material, equipment and accessory appurtenances in place or stored to date at the above referenced project: 881,569.00 esL s 5 % retained) 44,078.45 Total earned less retainer 837,490.55 Less Previous applications 793,412.10 TOTAL DUE THIS ESTIMATE NO: 9 44,078.45