THERMAL SUPPLY FIRE STOP- 332- 8/11/2011 Thermal Supply fire Stop Check: 332
7301 Georgetown Road #118 Date: 8/11/2011
Indianapolis, IN 46268 Vendor: THERMAL1
Prior
Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid
4 41,220.00 41,220.00 0.00 0.00 41,220.00
App 4 on theater
41,220.00 41,220.00 0.00 0.00 41,220.00
332
8/11/2011 **********41,220.00
THE SUM OF FORTY ONE THOUSAND TWO HUNDRED TWENTY DOLLARS AND NO CENTS
Thermal Supply fire Stop
7301 Georgetown Road #118
Indianapolis, IN 46268
Thermal Supply fire Stop Check: 332
7301 Georgetown Road #118 Date: 8/11/2011
Indianapolis, IN 46268 Vendor: THERMAL1
Prior
Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid
4 41,220.00 41,220.00 0.00 0.00 41,220.00
App 4 on theater
41,220.00 41,220.00 0.00 0.00 41,220.00
APPLICATION AND CERTIFICATION FOR PAYMENT A1A DOCUMENT 6702 PAGE ONE OF I PAGES I
TO OWNER: Cannel Theater Dcydcpment Corporation.I PROJECT: VOCi.7Cl -Theater APPLICATION NO Four 14j Distribution to:
10163rd Avenue S.W. Suite 200 3 Center Green OWNER
Carmel. Indiana 46032 Cannel. Indiana 46032 ARCHITECT
PERIOD TO: 5?C?011 XX CONTRACTOR
FROM CONTRACTOR: 'Thermal Supply Fire Slop Sy: VIA ENGINEER: Signature Construction, LLC
7301 Georgetown Rd NI 18 720 Third Avenue. SW
Indianapolis, IN 46268 Carmel. Indiana 46032 PROJECT NO: 12012
CONTRACT DATE I.1 1.2011
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to lie 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,AIA Document 6703,is attached completed in accordance with the Contract Documents_that all amounts have been paid by
the Contractor for Work for which previous Gen i fcates for Payment were issued and
payments received from the Owner.and that current payment shown herein is now due.
I. ORIGINAL CONTRACT SLIM $ 182,600.00
2. Net change by Chance Orders S 8,580.00 CONTRACTOR: Thermal Supply FSS,LLC.
3. CONTRACT SUM TO DATE(Line I:12) S 191.180.00
4. TOTAL COMPLETED&STORED'10 DATE S 124,350.00 ■ �
By: a ! • /A\,1 - _ \ '.ate: 5.16.2011
5. RETAIN.AGE: And rr' mAl, a
�_"lb'
a. 10 %of Completed Work S 12.435 Subscribed and sw am to -whir/ ::us.q ; I May 2011
(Column l)+E on 0703) \a... .•i Tit
b. °o of Stored Material $ 0 Kathleen L.Hamstra Reside • criilriclys C. July 28,2016
'Total Retainage((Lines 5a+5b or � • • , N L.0.0-4,
s 'I g.
Total in Column i of 6703) $ 12,435.00 ENGINEER'S CERTIFICA 7.-e4-A.r- •' •`•'"r.: NT
6. TOTAL EARNED LESS RE'TAINAGE S 11 1 915.00 In accordance with the Contract Documents,based o •'rat crvat'%.s and the data
(Lint 4 Less Line 5 Total) comprising the application,the Engineer certifies to the cr than - se best of the
7. LESS PREVIOUS CERTIFICATES FOR Engineer'ss knowledge,information and belief the Work has p•:��d as indicated,
PAYMENT(Line 6 from prior Certificate) S 70,695.00 the quality of the Work is in accordance with the Contract Docun-nts,and the Contractor
8. CURRENT PAYMENT DUE 5 41.220.00 is entitled to payment of the AMOUNT CEIYfIFI ED.
9. BALANCE TO FINISH,INCLUDING RETAINAGE S 79,265.00
(Line 3 less Line 6) AMOUNT CERTIFIED $ 9 /-7
/ 2
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation if amou nt certified dyers from the amount applied.Initial al/figures on this
Total changes approved Application and auNJre Continuation Sheer that are changed to conibrrn with the amount certified
TTotal pr Change Orders $5,970.00 $L90R0(I . B2i@FtCLrit 1/ `-'`" ""L// �` /,
Tntat approved this Change Order $5,970.00 By: Date:
TOTALS $10,480.00 $1,900,00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
Contractor named herein. Issuance,payment anti acceptance 01 payment are without
NET CHANGES by Change Order $8.580.00 prejudice to any rights of the Owner or Contractor under this Contract.
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AIA DOCUMENT 0702'APPLICATION AND CERTIFICATION FOR PAYMENT'1992 EDITION'AIA '01992 THE AMERICAN INSTITUTE OF ARCHITECTS,1735 NEW'TORE AVE..11 W.,'WASHINGTON,DC 20096-5292
Users may obtain validation of this document by requesting a completed AIA Document D401 -Certification of Document's Authenticity from the Licensee.
•
G703 CONTINUATION SHEET Paget of 1
To: From: Project: Application No.: Four(4) v
Carmel Theater Develepment Corporation, LLC Thermal Supply FSS, LLC. VOG.7C1 - Theater Application Date: 5.16.2011
11711 North Pennsylvania St, Suite 200 7301 Georgetown P.D.N118 3 Center Green Period To: '5.25.2011
Cannel, Indiana 46032 Indianapolis, IN 46268 Carmel, Indiana 46032 Project No.: 12012
I A B C D 1 E F G H
Work Comcleted Materials Total
Presently Completed Balance Retainage
Item Scheduled From Previous Stored and Stored I. To If
it Description of Work Value Application This Period (Not in To Date (G/C) Finish Variable
D or 5) (D4E+F) (C-G)
107-3000 Joint Sealants Materials: 17,000.00 2,100.00 6,400.00 0.00 8,500.00 50% 8,500.00 850.00
107-3001 Joint Sealants Labor: 36,500.00 4,300.00 14,000.00 0.00 18,300.00 50% 18,200.00 1,830.00
107-3002 Expansion Materials: 10,200.00 8,500.00 0.00 0.00 8,500.00 83% 1,700.00 850.00
107-3003 Expansion Labor: 23,600.00 0.00 10,000.00 0.00 10,000.00 42% 13,600.00 1,000.00
107-3004 Acoustical Sealant Materials: 13,000.00 11,000.00 1,000.00 0.00 12.000.00 92% 1,000.00 1,200.00
107-3005 Acoustical Sealant Labor: 17,000.00 13,000.00 2,000.00 0.00 15,000.00 88% 2,000.00 1,500.00
107-3006 Firestopping Materials: 20,800.00 16,000.00 3,000.00 0.00 19,000.00 91% 1,800.00 1,900.00
107-3007 Firestopping Labor: 21,000.00 16,000.00 3,000.00 0.00 19,000.00 90% 2,000.00 1,900.00
107-3008 Fireproofing Materials: 3,000.00 0.00 0.00 0.00 0.00 0% 3,000.00 0.00
107-3009 Fireproofing Labor: 2,000.00 0.00 0.00 0.00 0.00 0% 2,000.00 0.00
107-3010 Bond: 3,500.00 3,500.00 0.00 0.00 3,500.00 100% 0.00 350.00
107-3011 ALLOWANCE 15,000.00 0.00 3.500.00 0.00 3,500.00 23% 11,500.00 350.00
107-3012 CO 49 Tax Exempt: (1,900.00) 0.00 0.00 0.00 0.00 0% (1,900.00) 0.00
107-3013C0 73 PR 09 4,150.00 4,150.00 0.00 0.00 4,150.00 100% 0.00 415.00
107-3014C0 47 PR 017 360.00 0.00 0.00 0.00 0.00 0% 360.00 0.00
107-3015C0146 PR 43 5,970.00 0.00 2,900.00 2,900.00 49% 3,070.00 290.00
191,180,00 78.550.00 45,800.00 0.00 124,350.00 65% 66.830.00 12,435.00
G703 CONTINUATION SHEET Page I of
To: From: _ Project: Application No.: Four(4).
Thermal Supply Fire Stop Systems.I.I.0 VO(:-7C1.(healer Application Date: 5.16 21111
7301 Georgetown Rd.Suite 118 Period To: 5,25.21111
Indianapolis,IN 46268 Eng.Proj#
A II C D l E F C II I
Work Completed \laterials Total
Presently Completed Balance Beta inage
Item Scheduled From Previous Stored and Stored b To If
# Description of Work Value Application This Period (Not in To Date (C/C) Finish Variable
D or F) (D+E+F) (C-G)
Allowance Tracking
CO.65 AS1.1115 2.350.00 0.00 2,350.00 11.1)1) 2350.90 100% 0.011 235.00
C.O.73 PR.09 12.650.00 (1.00 1.150.00 0.00 1,150.00 9% 11.500.90 115.1)1)
Total: 15.000.110 0.09 3,5011.00 0.00 3,500.00 23% 11,500.00 350.00
•
•
PRIME CONTRACTOR'S SWORN STATEMENT OF
INDEBTNESS & WAIVER OF LIEN
STATE OF Indiana
COUNTY OF Hamilton
• • •_• • . -_ _ _ _ _ . . ly-swor-n-upen-hisarfer oath disposes and says that:
1. He/she is the President (inserting sole proprietor, partner or corporate office held, as the case
maybe), of Thermal Supply FSS, LLC. 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 Firestop 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 2 3
I hermal Supply I-Sb. LLU. $41,220.UU Use of out stock Materials
#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 19th
day of April, 2011.
LC
(Autho i Representative of Prime Cone)
County of Marion )
State of Indiana ) /4"Mk
Subscribed and sworn to before me, a Notary '
y ' <yyOfid�d� .N` ounty and State,
This 18th ay of May 9011 �_,__,,-_N,y •.
(Notary Public) s
Kathleen L`HH\ ,.
(Printed Name)
My Commission Expires: July 28, 2016#589182 Reside in Hendricks County
NOTARY SEAL MUST APPEAR ON THIS FORM.