HomeMy WebLinkAboutSIGNATURE CONSTRUCTION, LLC- 002789- 3/22/2012 CARMEL REDEVELOPMENT COMMISSION 002786
Signature Construction, LLC Check: 2786
720 3rd Ave., SW Date: 3/22/2012
Carmel, IN 46032 Vendor: SIGNATO1
Prior
Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid
See Transmittal Sheet for check detail.
35,500.34 35,500.34 0.00 0.00 35,500.34
•
•
•
•
THE KEYTO DOCUMENT SECURITY-HEAT ACTIVATEDTHUMB PRINT.•ADDITIONAL SECURITY FEATURES INCLUDED'.SEE BACK FOR DETAILS: '
' ' .itS, 11 Carmel Redevelopment.COmmission
AA \ 30 West Main Street" A REGIONS 002786 .
I' A 20 1-421%740
/� Suite 220
"'" `� Carmel, IN 46032
1 n 2786
.
•, • DATE AMOUNT
' 3/22/2012 35,500:34
PAY THE SUM OF.THIRTY'FIVE THOUSAND FIVE HUNDRED DOLLARS AND 34 CENTS
TO THE -
ORDER
OF Signature Construction, LLC ,
720,ard-Ave., SW ' '
Carmel, IN 46032
000 2 78611' 1:0 740 14 2 1 31: 008 7 504 1 L 111' -
CARMEL REDEVELOPMENT COMMISSION 0027186
Signature Construction, LLC Check: 2786
720 3rd Ave., SW Date: 3/22/2012
Carmel, IN 46032 Vendor: SIGNATO1
Prior
Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid
See Transmittal Sheet for check detail.
35,500.34 35,500.34 0.00 0.00 35,500.34
I
I
•
(-11-52 COMPUTEREASE FORMS DIVISION(877)577-5791 T-37228 62112
Transmittal Sheet Page 1
Carmel Redevelopment Comm
Signature Construction, LLC Check: 2786
720 3rd Ave., SW Date: 3/22/2012
Carmel, IN 46032 Vendor: SIGNATO1
Prior
Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paic
1-A 314.00 314.00 0.00 0.00 314.0C
LaFever site amenities
2&3 27,562.00 27,562.00 0.00 0.00 27,562.0(
snow removal
4-A 82.40 82.40 0.00 0.00 82.4C
• App 4 on Smock site amenities
5A 7,541.94 7,541.94 0.00 0.00 7,541.94
P112 Motor Court-Veneer
35,500.34 35,500.34 0.00 0.00 35,500.34
•
_HBignature
onstruction, ac
•
Carmel Redevelopment Commission
Parcel 5 Plaza - Snow & Ice Removal
702 South Rangeline Road
Carmel, IN 46032
ATTN: Matt Worthley
INVOKE
Date: March 6, 2012 Invoice: 0003
Snow and ice removal costs for the following:
2-6-12 - Ice Melt $876
Fees $238 Total 2-6-12 = $1114
2-10.12 - Ice Melt $876
Fees $238 Total 2-10-12 = $1114
2-11-12 - Snow Removal $2500
Ice Melt $876
Fees $475 Iota! 2-11-12 = $3851
2-14-12 - Ice Melt $876
Fees $238 Total 2-14-12 = $1114
TOTAL INVOICE $ 7,193
P1 a n rna�;? chock p;i,able to: Signature Construction, LLC
ha,4i questions, [lease contact Jason Springer at 317-945-7915,
One Pedcor Square
720 3rd Avenue, S.W. • Carmel, IN 46032
Tel 1317) 817-0360• Fax (317) 817-0362
ignature
onstruction , LLC
Carmel Redevelopment Commission
Parcel 5 Plaza - Snow & Ice Removal
702 South Rangeline Road
Carmel, IN 46032
" ATTN: Matt Worthley
INVOICE
Date: February 3, 2012 Invoice: 0002
Snow and ice removal costs for the following:
1-19-12 - Snow Removal $2500
Ice Melt $876
Fees $475 Total 1-19-12 = $3851
1-20-12 - Snow Removal $2500
Ice Melt $876
Fees $475 Total 1-20-12 = $3851
1-21-12 - Snow Removal $2500
Ice Melt $876
Fees $475 Total 1-22-12 = $3851
1-23-12 - Ice Melt $876
Fees $238 Total 1-24-12 = $1114
1-26-12 - Snow Removal $2500 �I
Ice Melt $876
Fees $475 Total 1-26-12 = $3851
1-28-12 - Snow Removal $2500
Ice Melt $876
Fees $475 Total 1-28-12 = $3851
TOTAL INVOICE $ 20,369
Please make check payable to: Signature Construction, LLC
If you have questions, please contact Jason Springer at 317-945-7915.
•
•APPLICATION AND CERTIFICATION FOR PAYMENT .41.4 DOCUMENT G702 PAGE ONE OF 2 PAGES2
TO OWNER CRC at City of-Came! PROJECT' 2112 Motor(nun APPLTCATION NO Invoice it 9-4 Distribution to:
Carmel Indiana 46032 Venevr Signature costs OWNER
ARCHITECT
PERIOD'1'O' 02/2512012 X CONTRACTOR
FROM CON'TRAC'TOR: VIA ARCHITECT: Peden Design
Signature Construction Services LLC
720 3rd Avenue S.W. PROJECT NOS:
Carmel,_ Indiana 46032
CONTRACT FOR: CONTRACT DATE:
CONTRACTOR'S APPLICATION FOR PAYMENT the undersigned Contractor certifies that to the best of the Contractors knowledge.
Application is made for payment,as shown below,in connection with the Contract. information and belief the Work covered by this Application for Payment has been
Continuation Sheet,MA Document G703,is attached. 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_
1. ORIGINAL CONTRACT SUM $ 49,100.00
2 Net change by Change Orders $ 000 CONTRACTOR:
3. CONTRACT SUM TO DA FE(Line 1 =2} $ 49,100.00 t
.7 777 4. TOTAL COMPL331'ED k STORE:D TO S 30 34621
13y: / 1 2 Date: '1Z52/,-'
5 RIrFAINAGE: /Thomas E.IC ntz.President s/ `
a 0 St of Completed Work $ 0 SR scribed and sw rn to before me this 0-3 da_v of he h LINDA G.BUCHANAN
(Column D+Eon 0703) \ e" Hancock County
b. %of Stored Material $ ,
(Column P on 6703) sx , My Commission Expires
Total Ref ainage(Lines 5a+Sb or '�"r;;;:?" August 20,2019
Total in Column 1 of 0703) $ o.00 ARCHITECT'S ERTIFICATE FOR P ENT
6 TOTAL EARNED LESS RHTAINAGE $ 30,346.21 in accordance with the Contract Documents,based on on-site observations and the data
(Line 4 Less Line 5 Total) comprisine the application,the Architect certifies to the Owner that to the best of the
7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge,information and belief the Work has progressed as indicated.
PAYMENT(Line 6 from prior Certificate} $ 22,804.27 the quality of the Work is in accordance with the Contract Documents,and the Contractor
8. CURRENT PAYMENT DUE $ 7, 41,4 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH,INCLUDING RETAINAGE 5 18,753.79 f
(Line 3 Tess Line 6) AMOUNT CERTIFIED $ 1 Si l. Cit_
CHANCE ORDER SUMMARY ADDF IONS DEDUCTIONS (Attach explanation ifantwmt reelViied dilfersfrom the amolin!applied-Initial o!(frgures on this
Total changes approved Application and aethe Coin ' - coy-ee khar are changed to conform with the amount certified)
in previous months by Owner ARCLLITEC
Iotal approved this Month lay' y 4.r_ lit Data .1.. L3) ra-
TOTALS SD 00 50.00 this Certifu-le is not i gr iabl �10 IN CERTIFIEiD is payable Iv to tiro
contractor ii -'ea her .Issuance,payment and acceptance Cl payment arc wiLnettt
NET CHANGES by Change Order $0.00 prejudice to any rig is of the Owner or Contractor under this Contract.
AM DOCUMENT G702-APPLICATION AND CERTIFICATION HOP PAYMENT-1972 EDITION NIA 01952 THE AMERICAN INSTITUTE OF ARCHITECTS,1735 NEW YORK AVE,.YW..WASHINGTON -5252
Users may obtain validation of this document by requesting a completed AIA Document.0401 -Certification of Document's Authenticity from the Licen e.
-21-6flz
•
SIGNATURE CONSTRUCTION LLC
720 3rd Avenue, S. W.
Carmel, Indiana 46032
Invoice # 5
2/25/12
P112 Motor Court Veneer - 12036
Carmel, Indiana
NORF. COMPLETED MATERIALS TOTAL BALANCE
ITEM DESCRIPTION OF SCHEDULED FROM PREVIOUS THIS PRESENTLY COMPLETED AND TO Committed
NO. WORE VALUE APPLICATIONS PERIOD STORED STORED TO DATE 6 FINISH Cost
General Regnirements:
Site Supervision 9,500.00 9,500.00 0.00 0.00 9,500.00 100% 0.00 9,500.00
Site Supervision Alt 1 6 5 14,050.00 2,251.45 5,575.89 0.00 7,827.34 56% 6,222.68 7,827.34
CRC Meetings 1,000.00 102.82 219.55 0.00 322 37 32% 677.63 322,37
Construction Management Fee 10,500.00 9,595.00 0.00 0.00 0,595.00 923 1,905.00 8,595.00
Construction Management Fee Alt 16 5 14,050.00 2,355.00 1,746.50 0.00 4,101.50 29% 9,949.50 4,101.50
49,100.00 22,804.27 7,541.94 0.00 30,346.21 626 8,805.29 26,244.71
CONDITIONAL AFFIDAVIT AND WAIVER OF LIEN
STATE OF INDIANA )
COUNTY OF HAMILTON )
Thomas E. Koontz being duly sworn states that he is the President of Signature
Construction, LLC having contract to furnish certain materials and/or labor as
follows: Construction Management Services for a project known as
P112 Motor Court Veneer, located at Carmel, Indiana and owned by the
Carmel Redevelopment Commission and does state:
CONDITIONAL WAIVER:
that the balance due from the owner is the sum of seven thousand
five hundred forty-one dolllars and ninty-four cents ($7,541.94) the
payment of which has been promised as the sole consideration for this Affidavit
and Conditional Waiver of Lien which is given to and for said amount, effective
upon receipt of such cash payment.
THEREFORE, the undersigned waives and releases unto the Owner of said premises any
and all line or claim whatsoever on the above-described property and improvements
thereon on account of labor or material or both, furnished by the undersigned thereto, and
further certifies that no other party has any claim or right to a lien on account of any
work perform or material furnished to the undersigned for the said project, and within the
scope of this affidavit and waiver.
SIGNATURE CONSTRUCTION, LLC
i
/ j i .
Th mas E400ntz, President
t
Subscribed and sworn to before me this:p,A. a3 _70/a
Notary Public: �j 0�,„/, �,4- .✓
( s ;.., LINDA D BUCHANAN
I. ;K,.,,!"' Hancock County
1 ,„ M,Commission Expires kt to.4„:. August 20,2019___
APPLICATION AND CERTIFICATION FOR PAYMENT ALA DOCUMENT G702 PAGE ONE OF 2 PAGE52
TO OWNER CRC at CAy of Came/ PROJEC U: Sirs Amenities APPLICATION NO Invoice'44-4- Distribution to:
Carmel Indiana 46032 Smock Signature costs OWNER
ARCHITECT
PERIOD TO: 02/25/2012 X CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT:I'edcor Design
Signature Construction Services LLC
-
720 3rd Avenue S-W. PROJECT NOS:
Cannel. Indiana 46032
CONTRACT'FOR: CONTRACT DATE:
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the hest of the Contractor's knowledge,
Application is made for payment,as shown below,in connection with the Contract information and belief the Work covered by this Application for Payment has been
Continuation Sheer,ANA Document 0703,is attached. 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.
1- ORIGINAL CONTRACT SUM S 5,19850
2. Net change by Change Orders S 090 CONTRACTOR:
3. CONTRACT SLIM TO DATE(Line I m 2) S 5,198.50
4. TOTAL COMPLETED Sc STORED TO S 5,198.50 ��
By: _-----17 [late:_ 2/2371/-,...—
5. RETAINAGE' T bomaa'P Koont',President f ' ,
a- 0%of Convicted Work 5 0 5 bscribed a sworn to before me this - �` day of Feb Jet, 'k/'4 LINDA G.BUCHANAN
(Column 17+Eon 0703) 4 ! ... Hancock County
b. %of Stored Material $ ` - '. ;E,:,. ;'` My Commission Expires
(Column F on 0703) ''A.,y(;rt,?'i' August 20,2019
Total Retainage(l.ines 5a+fib or
Total in Column I of 0703) $ 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT
O. TOTAL EARNED LESS RETAINAGE $ 5,19850 In accordance with the Contract Documents,based on on-site observations and the data
(Line 4 Less Line 5 Total) comprising the application,the Architect certifies to the Owner that to the best of the
7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge.information and belief the Work has progressed as indicated,
PAYMENT(Line 6 from prior Certificate) $ 5,116.10 the quality of the Work is in accordance with the Contract Documents,and the Contractor
S. CURRENT PAYMENT DUE 5 82,40 is entitled to payment of the AMOUNT CERTIFIED.
9, DALANCE TO FINISH,INCLUDING RETAINAGE $ 0.00
(Line 3 less Line 6) AMOUNT CERTIFIED_, . ......, .$ .41a_.
CHANGE ORDER SUMMARY ADDITIONS DEDUC LIONS (Attach explu dam il amount certified dpersfrorn the amount applied Initr)l all figrves on this �(�
'Total changes approved elpplrmtiom and ant Continr Sheet that are changed to conform with the nmounl cert jed.J I
in previous months by Owner ARCEnT-)T: '/{//1�
Total approved this Month By
� �J Y Dale //7
TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
Contractor named nerem.Issuance,payment anti acceptance at payment are without
NET CHANCES by Change Order $0.00 prejudice to any rights of the Owner or Contractor under this Contract.
ALA DOCUMENT 0702-APPLICATION AND CERTIFICATION FOR PAYMENT.1992 EDITION-AIA 01592 THe AMERICAN INSTITUTE OF ARCHITECTS.1735 NEW YORK AVE..N W.WASHINGTON,LC 20066.5292
Users may obtain validation of this document by requesting a completed AIA Document 0401 -Certification of Document's Authenticity from the Licensee.
•
SIGNATURE CONSTRUCTION LLC
720 3rd Avenue, S. W.
Carmel, Indiana 46032
Invoice # 4
2/25/12
P112 Site Amenities - Smock
Carmel, Indiana
WORK COMPLETED MATERIALS TOTAL BALANCE
ITEM DESCRIPTION OF SCHEDULED FROM PREVIOUS THIS PRESENTLY COMPLETED AND TO Committed
NO. WORK VALUE APPLICATIONS PERIOD STORED STORED TO DATE % FINISH Cost
General Requirements:
Site Supervision 2,599.25 2,516.85 82.40 0.00 2,599.25 100% 0.00 2,599.25
Construction Management Fee 2,599.25 2,599.25 0.00 0.00 2,599.25 100% 0.00 2,599.25
5,198.50 5,116.10 82.40 0.00 - . 5,198.50 1006 0.00 5,198.50
CONDITIONAL AFFIDAVIT AND WAIVER OF LIEN
STATE OF INDIANA
COUNTY OF HAMILTON )
Thomas E. Koontz being duly sworn states that he is the President of Signature
Construction, LLC having contract to furnish certain materials and/or labor as
follows: Construction Management Services for a project known as
Site Amenities, located at Carmel, Indiana and owned by the
Carmel Redevelopment Commission and does state:
CONDITIONAL WAIVER:
that the balance due from the owner is the sum of
eighty-two dollars and forty cents ($82.40) the
payment of which has been promised as the sole consideration for this Affidavit
and Conditional Waiver of Lien which is given to and for said amount, effective
upon receipt of such cash payment.
THEREFORE, the undersigned waives and releases unto the Owner of said premises any
and all line or claim whatsoever on the above-described property and improvements
thereon on account of labor or material or both, furnished by the undersigned thereto, and
further certifies that no other party has any claim or right to a lien on account of any
work perform or material furnished to the undersigned for the said project, and within the
scope of this affidavit and waiver.
SIGNATURE CONSTRUCTION, LLC
Thomas . Koontz, President
\ / / /
Subscribed and sworn to before me this::/* #4 3 9_rila
Notary Public: , 4
g LINDA G.BUCHANAN
� "` Hancock County
:-x;,• My Commission Expires
August20,2019
•
APPLICATION AND CERTIFICATION FOR PAYMENT A1A DOCUMENTG702 PAGE ONE OF 2 PAGES2
TO OWNER CKC at City of Cannel PROJECT: Site Amenities APPLICATION NO Invoice e I —,4 Distribution to:
Carmel Indiana 46032 tarever Signature costs OWNER
ARCFIrrECT-
PERIOD TO: 02/75/7012 X coNTRAC'I'OR
FROM CONTRACTOR: VIA ARCHITECT: Pcdcor Design
Signature Construction Services I.LC 1
720 3rd Avenue S.W. PROJECT NOS:
Carmel, Indiana 46032
CONTRACT FOR: CONTRACT DATE:
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractors knowledge,
Application is made for payment,as shown below.in connection with the Contract information and belief the Work covered by this Application for Payment has been
Continuation Sheet.AA Document G703,is attached. 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,
L ORIGINAL CONTRACT SUM $ 314.00
2. Net change by Change Orders $ 0.00 CONTRACTOR:
3. CONTRACT SUM TO DATE(Line 1 ±2) $ 314.00
4. TOTAL COMPLE'T'ED&STORED TO S 314.00
By: 77---------r Date: Z/25/22-.
5. RETAINAGE: Thomas E. oontz,President ice-
a. 0 °A of Completed Work $ 0 Sub crihed an worn to before me this `75 day of F.�. Ja1 a
(Column D+E on G703) •M:; :.., LINDA G.BUCHANAN
b. %of Stored Material s / ,', ruty�*_ Hancock County
(Column I'on 0703) a,4i My Commission Expires
Total Retainaee(Lines 5a+Sb or "!?;b:, August 20,2019
Total in Column l of 0703) $ 0.00 ARC C-T'S CERTIFICATE FOR I AYMEN
6. TOTAL EARNED LESS RETAINAGE $ 314.00 In accordance with the Contract Documents,based on on-site observations and the data
(Line 4 Less Line 5 Total) comprising the application,the Architect certifies to the Owner that to the best of the
7. LESS PREVIOUS CERTIFICATES FOR Architects knowledge,information and belief the Work has progressed as indicated.
PAYMENT(Line 6 from prior Certificate) $ 0.00 the quality of the Work is in accordance with the Contract Documents,and the Contractor
8. CURRENT PAYMENT DUE $ 314.00 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH,INCLUDING RETAINAGE $ 0.00
(Line 3 less Line 6) AMOUNT CERTIFIED S Nics CO
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation if oum certified differs from the amount applied.Initial all figures on this
Total changes approved Application and o ue Cr Su r Sheet that are changed to conform with the amount certified)
in previous months by Owner ARCHITECT: _ /q t�
Total approved this Month By: `� /' Date: A/iti t
TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
Contractor named herein. Issuance,payment and acceptance of payment are wttnout
NET CHANGES by Change Order $0.00 prejudice to any rights of the Owner or Contractor under this Contract.
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 20009-5292
Users may obtain validation of this document by requesting a completed AIA Document D401 -Certification of Document's Authenticity from the Licensee.
SIGNATURE CONSTRUCTION LLC
720 3rd Avenue, S. W.
Carmel, Indiana 46032
Invoice # 1
2/25/12
•
P112 Site Amenities - Broady
Carmel, Indiana
WORK COMPLETED MATERIALS TOTAL BALANCE
ITEM DESCRIPTION OF SCHEDULED FROM PREVIOUS THIS PRESENTLY COMPLETED AND TO Committed
NO. WORK VALUE APPLICATIONS PERIOD STORED STORED TO DATE % FINISH Cost
General Requirements:
Site Supervision 157.00 0.00 157.00 0.00 157.00 100% 0.00 157.00
' Construction Management Fee 157.00 0.00 157.00 0.00 157.00 100% 0.00 157.00
314.00 0.00 314.00 0.00 314.00 100% 0.00 314.00
CONDITIONAL AFFIDAVIT AND WAIVER OF LIEN
STATE OF INDIANA )
COUNTY OF HAMILTON )
Thomas E. Koontz being duly sworn states that he is the President of Signature
Construction, LLC having contract to furnish certain materials and /or labor as
follows: Construction Management Services for a project known as
Site Amenities, located at Carmel, Indiana and owned by the
Carmel Redevelopment Commission and does state:
CONDITIONAL WAIVER:
that the balance due from the owner is the sum of
three hundred fourteen dollars and zero cents ($314.00) the
payment of which has been promised as the sole consideration for this Affidavit
and Conditional Waiver of Lien which is given to and for said amount, effective
upon receipt of such cash payment.
THEREFORE, the undersigned waives and releases unto the Owner of said premises any
and all line or claim whatsoever on the above-described property and improvements
thereon on account of labor or material or both, furnished by the undersigned thereto, and
further certifies that no other party has any claim or right to a lien on account of any
work perform or material furnished to the undersigned for the said project, and within the
scope of this affidavit and waiver.
SIGNATURE CONSTRUCTION, LLC
r
Thbmas ' ontz, President
Subscribed and sworn to before me this: / L-Z . 2 3 , 0/3.
�J
i
Notary Public:�„u4r —A ,w 9 ..�
•s+;. LINDA G.BUCHANAN
f , `'b• Hancock County
<: si;,. rte` My Commission Expires
`4'.?;a'r?" August 20,2019
Prescribed by State Board of Accounts City Form No.201(Rev.1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Ac e' • Cci,2 /roc f',,ty S..-t',y�7 L` c Purchase Order No.
72d .1&' Terms
Ceirrn /,nJ S%o 32 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
'Z-25-/2- 1 - / 5r tr Sn,oc ;� .ci'O
2 -25-)2 /-. g P/ 2 /7y'fdv Co4,-t- P5 7Sy/, 99
;r: r
• C
1.
Total 7, 9 3 3.'".397.
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct an• same in accor-
ance with IC 5-11-10-1.6. �
,3 -2 ,1 , 20 1Z _
•' -Treasurer
Prescribed by State Board of Accounts City Form No.201(Rev.1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
•
Payee
S15' eY •'r Co.027 roc f`c7, Purchase Order No.
(J,�r J�Poror 5 ow'--
720 "3er- `'u�,, - Terms
Crlt'f�-/, (�'� 'r/O 32_ Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
3-G-/2 3 5),en) r o✓ri / r/> a . 20/2 7/9 3.o0
2.3 2 20 12 20 369 •U0
•
c,
.c
_ 141
is
Total 23 562.04 c
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have a •' - : same in accor-
dance with IC 5-11-10-1.6.
2 -Z-1 , 20 17--_
� o
Glcik Treasurer