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HomeMy WebLinkAboutHAGERMAN CONSTRUCTION CORP- 001347- 11/18/2010 n •..,ARMEL REDEVELOPMENT COMMISSION 0013,47 Hagerman Construction Corp Check: 1347 10315 Allisonville Road Date: 11/18/2010 Fishers, IN 46038-2016 Vendor: HAGEERM1 Prior Invoice ` P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid 27 29 50,000.00 50,000.00 0.00 0.00 50,000.00 Application 27 9433-1 60 -2,500.00 -2,500.00 0.00 0.00 -2,500.00 Application 17 47,500.00 47,500.00 0.00 (100 47,50(100 MaitinnenriaaTH IS'CHECK,HAS,'A`COLORED;BACKGROUND'ANWCONTAINS;MULTIP ESECURTME,EATURES"=SEMACK'FOR?DETAILS ;an... s"ES Carmel Redevelopment Commission 'Alt. ,�ti p 001347 30 West Main Street REGIONS Suite 220 20-1421/740 oCARME`c Carmel, IN 46032 • ..... /STRIL 1347 DATE AMOUNT 11/18/2010 ******"****"47,500.00 PAY THE SUM OF FORTY SEVEN THOUSAND FIVE HUNDRED DOLLARS TO THE ORDER OF Hagerman Construction Corp 10315 Allisonville Road PS sE"S,,m .. Fishers, IN 46038-2016 1. " OOL34 ?0 I:0 ?40L42L31: 008 7504LLL0 CARMEL REDEVELOPMENT COMMISSION 001347 Hagerman Construction Corp Check: 1347 10315 Allisonville Road Date: 11/18/2010 Fishers, IN 46038-2016 Vendor: HAGEERM1 Prior Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid 27 29 50,000.00 50,000.00 0.00 0.00 50,000.00 Application 27 9433-1 60 -2,500.00 -2,500.00 0.00 - 0.00 -2,500.00 Application 17 47,500.00 47,500.00 0.00 0.00 47,500.00 �� ® ye• Document G702/CMa TM - 1992 9 Application and Certificate for Payment Construction Manager-Adviser Edition TO OWNER: PROJECT:Parcel /A, Regionsl xtorming Arts APPLICATION NO: 2 Distribution to: Carmel Redevelopment ''Commission Carter City of Carmel HCC Job #2613 PERIOD TO 09/30/10 OWNER ❑ Carmel, IN 46032 Invoice #9944 CONSTRUCTION MANAGER ❑ FROM CONTRACTOR: VIA CONSTRUCTION MANAGER: CONTRACT DATE: ARCHITECT ❑ Hagerman Construction Corporation P.O. Box 10690 Shiel Sexton PROJECT NOS: 2695 / / CONTRACTOR ❑ Fort Wayne, IN 46853 VIA ARCHITECT: FIELD ❑ CONTRACT FOR: CSO Architects ❑ CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and Application is made for payment,as shown below,in connection with the Contract. 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 Continuation Sheet,AIA Document G703,is attached. Certificates for Payment were issued and payments received from the Owner, and that current 1.ORIGINAL CONTRACT SUM $5,588,000_00 payment shown herein is now due. Hagerman Construction Corporation 2. Net change by Change Orders $ 393,671,00 CONTRACTOR: 011441494 3.CONTRACT SUM TO DATE(Line 1 ±2) $5,931,671.00 By: Date:..i1 44•< , 17, 2010 4.TOTAL COMPLETED&STORED TO DATE(Column G on G703) $5,968,893,00 State of: Richard E. utorius, Secretary OON$068�a e�.,� 5.RETAINAGE: County of: Allen o VOA` jeril6-44,; T. a. %of Completed Work Subscribed and sworn to before °,4`�"1;'0' 1`411 I �N p ( G703) 299,083.55 y :,.t- 1`a o, , e 0 .•• ei Coo•D • Column D+Eon G703 $ 299, 83.55 me this 17th day e ' b. %of Stored Material Notary Pub ,... p _ — , - ; NOT}1MS(31. oIX (Column F on G703) $ My Commission expo•s: 5 ,° ,t . Total Retainage(Lines 5a+5b or Total in Column I of G703).. $ 299,033.55 CERTIFICATE FOR PAYMENT 'gyp�•..,��.���oY In accordance with the Contract Documents, based on on-site observation s�ii %tt���a comprising 6.TOTAL EARNED LESS RETAINAGE $ 5,669,809.45 this application,the Construction Manager and Architect certify to the Owner that to the best of their (Line 4 Less Line 5 Total) knowledge,information and belief the Work has progressed as indicated,the quality of the Work is in 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT $ 5,622,3)9.45 accordance with the Contract Documents,and the Contractor is entitled to payment of the AMOUNT (Line 6 from prior Certificate) CERTIFIED. 8.CURRENT PAYMENT DUE $ 47,500.00 AMOUNT CERTIFIED $ 4715 9.BALANCE TO FINISH,INCLUDING RETAINAGE (Attach explanation if amount certified dill, s fr in the amount applied. Initial all figures on this Application and on the Continuati, Shee that(re changed to conform with the at ount certified.) (Line 3 less Line 6) $ 311,861.55 CONST' CTIO E': BY ,∎10'. i_lJ, _ ® Date: el 2/ /a CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHITECT: '-' Total changes approved in previous months by Owner $371,646. 27,975.00 By �t Date Total approved this Month $ 50,000. _0_ This Certificate is not negotiable. The AMOUNT CERTIFIED is payable onl to the Contractor TOTALS $421,646. 27,975.00 named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of NET CHANGES by Change Order $393,671.00 the Owner or Contractor under this Contract. • 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. t• AIA Document G702/CMaTM-1992.Copyright ©1992 by The American Institute of Architects.All rights reserved.WARNING:This AlA® Document is protected by U.S.Copyright Law and International Treaties. r.Jnauthorized 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. e.— Document G702/CMaTM - 1992 Instructions Application and Certificate for Payment Construction Manager-Adviser Edition A.General Information AIA Document G702/CMa,Application and Certificate for Payment,Construction Manager-Adviser Edition,is to be used in conjunction with AIA Document G703, Continuation Sheet.These documents are designed to be used on a Project where a Construction Manager is employed as an adviser to the Owner,but not as a constructor,and where multiple Contractors have direct Agreements with the Owner.Procedures for their use are covered in AIA Document A201/CMa,General Conditions of the Contract for Construction,Construction Manager-Adviser Edition,1992 Edition. B.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/CMa,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. C.Completing the G702/CMa Form After the Contractor has completed AIA Document G703,Continuation Sheet,summary information should be transferred to AIA Document G702/CMa,Application and Certificate for Payment,Construction Manager-Adviser Edition. The Contractor should sign G702/CMa,have it notarized and submit it,together with G703,to the Construction Manager and Architect. The Construction Manager and Architect should review G702/CMa and G703 and,if they are acceptable,complete the Certificate for Payment on G702/CMa.The Construction Manager and Architect may certify a different amount than that applied for pursuant to Sections 9.5 and 9.6 of A201/CMa.They should then initial all figures on G702/CMa and G703 that have been changed to conform to the amount certified and attach an explanation.The completed G702/CMa and G703 should be forwarded to the Owner. D.Completing the G703 Form Heading:This information should be completed to be consistent with similar information on AIA Document G702/CMa,Application and Certificate for Payment, Construction Manager-Adviser Edition. Columns A,B&C:These columns should be completed by identifying the various portions of the Project and their scheduled value 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 bf 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 into the project which 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 G: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 G702/CMa form. 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.in,41,201/CMa: E.Making Payment The Owner should make payment directly to the Contractor based on the amount certified by the Construction Manager and Architect on AIA Document G702/CMa, Application and Certificate for Payment,Construction Manager-Adviser Edition:The•coriipl`eted form'contains the name and address of the Contractor.Payment should not be made to any other party unless specifically indicated on G702/CMa. AIA Document G702/CMa TM-1992.Copyright ©1992 by The American Institute of Architects.All rights reserved.WARNING:This AlA® 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 AIA DOCUMENT G703 PAGE 1 OF 5 PAGES AIA Document G702,APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 00027 containing Contractor's signed Certification, is attached. APPLICATION DATE: In tabulations below,amounts are stated to the nearest dollar. PERIOD TO: 9/30/2010 Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO.: 082613A A B C D E F G H I WORK COMPLETED MATERIALS TOTAL BALANCE RETAINAGE SCHEDULED PRESENTLY COMPLETED o TO (IF VARIABLE) ITEM DESCRIPTION OF WORK FROM I RLVIOUS o NO. VALUE STORED AND STORED FINISH APPLICATION LIGATION THIS 1 LRIOD (NOT IN TO DATE (G:C) RATE (C-G) (D=E-) D ORE) (D+E+F) 0000010 GENERAL CONDITIONS 0000020 Bond $41,375.00 $41,375.00 $0.00 $0.00 $41,375.00 100.000 $0.00 $0.00 0000030 General Conditions $169,586.00 $169,586.00 $0.00 $0.00 $169,586.00 100.000 $0.00 $0.00 0000040 Supervision/Engineering $320,164.00 $320,164.00 $0.00 $0.00 $320,164.00 100.000 $0.00 $0.00 0000045 Equipment/Operators $383,328.00 $383,328.00 $0.00 $0.00 $383,328.00 100.000 $0.00 $0.00 0000050 Owner Allowance $55,000.00 $42,222.00 $0.00 $0.00 $42,222.00 76.767 $12,778.00 $0.00 0000055 Subtotal General Conditions $969,453.00 $956,675.00 $0.00 $0.00 $956,675.00 98.682 $12,778.00 $0.00 0000060 EARTHWORK 0000070 Excavation/Backfill $795,000.00 $795,000.00 $0.00 $0.00 $795,000.00 100.000 $0.00 $0.00 0000080 Site Utilities $200,000.00 $200,000.00 $0.00 $0.00 $200,000.00 100.000 $0.00 $0.00 0000090 Soil Treatment(Termiticide) $6,448.00 $6,448.00 $0.00 $0.00 $6,448.00 100.000 $0.00 $0.00 0000095 Subtotal Earthwork $1,001,448.00 $1,001,448.00 $0.00 $0.00 $1,001,448.00 100.000 $0.00 $0.00 0000110 CONCRETE 0000120 Footings Labor $206,046.00 $206,046.00 $0.00 $0.00 $206,046.00 100.000 $0.00 $0.00 0000130 Footings Material $202,588.00 $202,588.00 $0.00 $0.00 $202,588.00 100.000 $0.00 $0.00 0000140 Foundation Walls/Piers Labor $603,561.00 $603,561.00 $0.00 $0.00 $603,561.00 100.000 $0.00 $0.00 0000150 Foundation Walls/Piers Material $414,224.00 $414,224.00 $0.00 $0.00 $414,224.00 100.000 $0.00 $0.00 0000160 Slabs on Grade Labor $47,650.00 $47,650.00 $0.00 $0.00 $47,650.00 100.000 $0.00 $0.00 0000170 Slabs on Grade Material $91,157.00 $91,157.00 $0.00 $0.00 $91,157.00 100.000 $0.00 $0.00 0000180 Elevated Slabs Labor $29,485.00 $29,485.00 $0.00 $0.00 $29,485.00 100.000 $0.00 $0.00 0000190 Elevated Slabs Material $24,740.00 $24,740.00 $0.00 $0.00 $24,740.00 100.000 $0.00 $0.00 0000200 Elevator Shafts Labor $167,945.00 $167,945.00 $0.00 $0.00 $167,945.00 100.000 $0.00 $0.00 0000210 Elevator Shafts Material $61,125.00 $61,125.00 $0.00 $0.00 $61,125.00 100.000 $0.00 $0.00 0000220 Columns Labor $134,436.00 $134,436.00 $0.00 $0.00 $134,436.00 100.000 $0.00 $0.00 0000230 Columns Material $51,221.00 $51,221.00 $0.00 $0.00 $51,221.00 100.000 $0.00 $0.00 0000240 Slabs on Metal Deck Labor $116,191.00 $116,191.00 $0.00 $0.00 $116,191.00 100.000 $0.00 $0.00 0000250 Slabs on Metal Deck Material $245,878.00 $245,878.00 $0.00 $0.00 $245,878.00 100.000 $0.00 $0.00 0000260 Topping Slab/Stair/Curb Labor $88,023.00 $88,023.00 $0.00 $0.00 $88,023.00 100.000 $0.00 $0.00 0000270 Topping Slab/Stair/Curb Material $61,026.00 $61,026.00 $0.00 $0.00 $61,026.00 100.000 $0.00 $0.00 0000280 Rebar Labor $239,605.00 $239,605.00 $0.00 $0.00 $239,605.00 100.000 $0.00 $0.00 0000290 Rebar Material $406,775.00 $406,775.00 $0.00 $0.00 $406,775.00 100.000 $0.00 $0.00 0000300 Misc.Metals Labor $27,015.00 $27,015.00 $0.00 $0.00 $27,015.00 100.000 $0.00 $0.00 . AIA DOCUMENT G703•APPLICATION AND CERTIFICATE FOR PAYMENT • 1992 EDITION • AIA(g)• ©1992 • THE AMERICAN INSTITUTE OF ARCHITECTS.1735 NEW YORK G703-1992 2 AVENUE.N.W..WASHINGTON.D.C. 20E06-5292 • WARNING: Unlicensed photocopying violates U.S.copyright laws and will subject the violator to legal prosecution. 'This document has been reproduced electronically with the permission of The American Institute of Architects under License 97003 to Primavera Systems,Inc.Reproduction of this document without project-specific information is not permitted.Contact The American Institute of Architects (. to verify the current version of this document and license status' CONTINUATION SHEET AIA DOCUMENT G703 PAGE 2 OF 5 PAGES AIA Document G702,APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 00027 containing Contractor's signed Certification,is attached. APPLICATION DATE: In tabulations below,amounts are stated to the nearest dollar. PERIOD TO: 9/30/2010 Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO.: 082613A A B C D E F G H I WORK COMPLETED MATERIALS TOTAL BALANCE ITEM DESCRIPTION OF WORK SCHEDULED FROM PREVIOUS PRESENTLY COMPLETED ale TO RETAINAGE _ STORED AND STORED FINISH NO. VALUE (�VARIABLE) APPLICATION THIS 1 f RIOD (NOT IN TO DATE (G C) RATE (C-G) (D+E) D OR E) (D+E+F) 0000310 Misc.Metals Material $38,003.00 $38,003.00 $0.00 $0.00 $38,003.00 100.000 $0.00 $0.00 0000315 Subtotal Concrete $3,256,694.00 $3,256,694.00 $0.00 $0.00 $3,256,694.00 100.000 $0.00 $0.00 0000330 THERMAL AND MOISTURE PROTECTION 0000340 Insulation Labor $3,877.00 $3,877.00 $0.00 $0.00 $3,877.00 100.000 $0.00 $0.00 0000350 Insulation Material $15,268.00 $15,268.00 $0.00 $0.00 $15,268.00 100.000 $0.00 $0.00 0000360 Waterproofing Labor $90,000.00 $90,000.00 $0.00 $0.00 $90,000.00 100.000 $0.00 $0.00 0000370 Waterproofing Material $122,960.00 $122,960.00 $0.00 $0.00 $122,960.00 100.000 $0.00 $0.00 0000380 Caulking Labor $13,300.00 $13,300.00 $0.00 $0.00 $13,300.00 100.000 $0.00 $0.00 0000390 Caulking Material $16,600.00 $16,600.00 $0.00 $0.00 $16,600.00 100.000 $0.00 $0.00 0000400 Subtotal Thermal&Moisture Protection $262,005.00 $262,005.00 $0.00 $0.00 $262,005.00 100.000 $0.00 $0.00 0000420 SPECIAL CONSTRUCTION 0000430 Vibration Sound Control-Jack Up Floor Systel $98,400.00 $98,400.00 $0.00 $0.00 $98,400.00 100.000 $0.00 $0.00 0000450 CHANGE ORDER#01 0000460 Alternate Parking ($20,000.00) ($20,000.00) $0.00 $0.00 ($20,000.00) 100.000 $0.00 $0.00 0000480 CHANGE ORDER#02 0000490 Oculus Alternate $10,000.00 $10,000.00 $0.00 $0.00 $10,000.00 100.000 $0.00 $0.00 0000510 CHANGE ORDER#03 0000520 PC 10R2-Elevator Changes $27,828.00 $27,828.00 $0.00 $0.00 $27,828.00 100.000 $0.00 $0.00 0000540 CHANGE ORDER#04 0000550 PC 10R2-Elevator Changes $11,926.00 $11,926.00 $0.00 $0.00 $11,926.00 100.000 $0.00 $0.00 0000570 CHANGE ORDER#05 0000580 PC 18-Sanitary Sewer Force Main Piping $9,707.00 $9,707.00 $0.00 $0.00 $9,707.00 100.000 $0.00 $0.00 0000600 CHANGE ORDER#06 0000610 PC 05R1 -ASI#2 Speaker Boxes $26,221.00 $26,221.00 $0.00 $0.00 $26,221.00 100.000 $0.00 $0.00 0000630 CHANGE ORDER#07 AIA DOCUMENT G703•APPLICATION AND CERTIFICATE FOR PAYMENT • 1992 EDITION • AIA®• rc,1992 • THE AMERICAN INSTITUTE OF ARCHITECTS,1735 NEW YORK G703-1992 AVENUE.N.W..WASHINGTON,D.C. 20006-5292 • WARNING: Unlicensed photocopying violates U.S.copyright laws and will subject the violator to legal prosecution. This document has been reproduced electronically with the permission of The American Institute of Architects under License 97003 to Primavera Systems,Inc. Reproduction of this document without project-specific information is not permitted.Contact The American Institute of Architects 1I. to verify the current version of this document and license status' CONTINUATION SHEET AIA DOCUMENT G703 PAGE_3OF5PAGES AlA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 00027 containing Contractor's signed Certification, is attached. APPLICATION DATE: In tabulations below,amounts are stated to the nearest dollar. PERIOD TO: 9/30/2010 Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO.: 082613A A B C D E F G H I WORK COMPLETED MATERIALS TOTAL BALANCE ITEM DESCRIPTION OF WORK SCHEDULED FROM PREVIOUS PRESENTLY COMPLETED 'Y. TO RETAINAGE NO. VALUE , STORED AND STORED FINISH (IF VARIABLE) API LICATION THIS I ERIOD (NOT IN TO DATE (G C) RATE (D+E) D OR E) (D+E+F) 0000640 PC 12R1 -Foundation Changes $5,744.00 $5,744.00 $0.00 $0.00 $5,744.00 100.000 $0.00 $0.00 0000660 CHANGE ORDER#08 0000670 PC#15R1 -Reduce Size of HDPE Pipe ($1,175.00) ($1,175.00) $0.00 $0.00 ($1,175.00) 100.000 $0.00 $0.00 0000690 CHANGE ORDER#09 0000700 PC 22-HDPE Single Wall Pipe $554.00 $554.00 $0.00 $0.00 $554.00 100.000 $0.00 $0.00 0000720 CHANGE ORDER#10 0000730 PC 23-Change Drainage Layer Stone $14,139.00 $14,139.00 $0.00 $0.00 $14,139.00 100.000 $0.00 $0.00 0000750 CHANGE ORDER#11 0000760 PC 04R2-ASI#1 Modification to Utility Tunne $1,757.00 $1,757.00 $0.00 $0.00 $1,757.00 100.000 $0.00 $0.00 0000780 CHANGE ORDER#12 0000790 PC 06R2-ASI#3 Added Columns $12,142.00 $12,142.00 $0.00 $0.00 $12,142.00 100.000 $0.00 $0.00 0000810 CHANGE ORDER#13 0000820 PC 09R2-ASI#6 Various Changes $22,449.00 $22,449.00 $0.00 $0.00 $22,449.00 100.000 $0.00 $0.00 0000840 CHANGE ORDER#14 0000850 PC 09R2-ASI#6 Various Changes $32,257.00 $32,257.00 $0.00 $0.00 $32,257.00 100.000 $0.00 $0.00 0000870 CHANGE ORDER#15 0000880 PC 02R1 -Added&Extended Piers $6,578.00 $6,578.00 $0.00 $0.00 $6,578.00 100.000 $0.00 $0.00 0000900 CHANGE ORDER#16 0000910 PC 35-Water Main Sleeve $1,757.00 $1,757.00 $0.00 $0.00 $1,757.00 100.000 $0.00 $0.00 0000930 CHANGE ORDER#17 0000940 PC 05R1 -Speaker Boxes-West $29,820.00 $29,820.00 $0.00 $0.00 $29,820.00 100.000 $0.00 $0.00 0000960 CHANGE ORDER#18 0000970 PC 34R2-ASI#40 Sanitary Force Main $18,987.00 $18,987.00 $0.00 $0.00 $18,987.00 100.000 $0.00 $0.00 AlA DOCUMENT G703•APPLICATION AND CERTIFICATE FOR PAYMENT • 1992 EDITION • AIA®• ©1992 • THE AMERICAN INSTITUTE OF ARCHITECTS.1735 NEW YORK G703-1992 • AVENUE.N.W..WASHINGTON.D.C. 20096-5292 • WARNING: Unlicensed photocopying violates U.S.copyright laws and will subject the violator to legal prosecution. 0 "This document has been reproduced electronically with the permission of The American Institute of Architects under License 97003 to Primavera Systems,Inc, Reproduction of this document without project-specific information is not permitted.Contact The American Institute of Architects to verify the current version of this document and license status" CONTINUATION SHEET AIA DOCUMENT G703 PAGE 4OF5PAGES AIA Document 0702,APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 00027 containing Contractor's signed Certification, is attached. APPLICATION DATE: In tabulations below,amounts are stated to the nearest dollar. PERIOD TO: 9/30/2010 Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO.: 062613A A B C D E F G H I WORK COMPLETED MATERIALS TOTAL BALANCE ITEM DESCRIPTION OF WORK SCHEDULED FROM PREVIOUS PRESENTLY COMPLETED % TO RETA[(IF VARIABLE) E NO. VALUE STORED AND STORED AB APPLICATION LICATION THIS PERIOD FINISH RATE (NOT IN TO DATE (G C) (C-CO (D+E) D OR E) (D+E+F) 0000990 CHANGE ORDER#19 0001000 Credit for Commercial Stone in lieu of INDOT ($6,800.00) ($6,800.00) $0.00 $0.00 ($6,800.00) 100.000 $0.00 $0.00 0001020 CHANGE ORDER#20 0001030 PC 26-ASI#11 Added Curbs $5,428.00 $5,428.00 $0.00 $0.00 $5,428.00 100.000 $0.00 $0.00 0001050 CHANGE ORDER#21 0001060 PC 27R2-ASI 17 Utilitly Vault Modifications $8,505.00 $8,505.00 $0.00 $0.00 $8,505.00 100.000 $0.00 $0.00 0001080 CHANGE ORDER#22 0001090 PC 07-Unsuitable Soils at Tunnel $22,060.00 $22,060.00 $0.00 $0.00 $22,060.00 100.000 $0.00 $0.00 0001110 CHANGE ORDER#23 0001120 PC 03-Unsuitable Soils $9,520.00 $9,520.00 $0.00 $0.00 $9,520.00 100.000 $0.00 $0.00 0001140 CHANGE ORDER#24 0001150 PC 33-Unsuitable Soils $3,678.00 $3,678.00 $0.00 $0.00 $3,678.00 100.000 $0.00 $0.00 0001170 CHANGE ORDER#25 0001180 PC 37-Generator Slab $2,132.00 $2,132.00 $0.00 $0.00 $2,132.00 100.000 $0.00 $0.00 0001200 CHANGE ORDER#27 0001210 PC 31 Added Masonry Footing $3,751.00 $3,751.00 $0.00 $0.00 $3,751.00 100.000 $0.00 $0.00 0001230 CHANGE ORDER#28 0001240 PC 41R1 ASI#27 SOG Modifications $4,293.00 $4,293.00 $0.00 $0.00 $4,293.00 100.000 $0.00 $0.00 0001260 CHANGE ORDER#29 0001270 PC 28R1 ASI#18 Garbage Vacuum Pit $3,181.00 $3,181.00 $0.00 $0.00 $3,181.00 100.000 $0.00 $0.00 0001290 CHANGE ORDER#30 0001300 PC 29 ASI#21 South Entrance Stairs $7,870.00 $7,870.00 $0.00 $0.00 $7,870.00 100.000 $0.00 $0.00 AIA DOCUMENT G703•APPLICATION AND CERTIFICATE FOR PAYMENT • 1992 EDITION • AIA®• 01992 • THE AMERICAN INSTITUTE OF ARCHITECTS.1735 NEW YORK G703-1992 AVENUE.N.W..WASHINGTON.D.C. 20006-5292 • WARNING: Unlicensed photocopying violates U.S.copyright laws and will subject the violator to legal prosecution. ra "This document has been reproduced electronically with the permission of The American Institute of Architects under License 97003 to Primavera Systems,Inc. Reproduction of this document without project.speciflc information is not permitted.Contact The American Institute of Architects to verify the current version of this document and license statue rr . CONTINUATION SHEET AIA DOCUMENT G703 PAGE 5 OF 5 PAGES AIA Document G702,APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 00027 containing Contractor's signed Certification, is attached. APPLICATION DATE: In tabulations below,amounts are stated to the nearest dollar. PERIOD TO: 9/30/2010 Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO.: 082613A A B C D E F G H I WORK COMPLETED MATERIALS TOTAL BALANCE RETArNAGE PRESENTLY COMPLETED VARIABLE) ITEM DESCRIPTION OF WORK SCHEDULED FROM PREVIOUS % TO (IF VARIABLBL E) NO. VALUE „ STORED AND STORED FINISH APPLICATION LIGATION TFIIS PERIOD (NOT IN TO DATE (G:C) RATE (C-G) (D+E) D OR E) (D+E+F) 0001320 CHANGE ORDER#31 0001330 PC 30R1 ASI#22 Platform Lift Plt $5,106.00 $5,106.00 $0.00 $0.00 $5,106.00 100.000 $0.00 $0.00 0001350 CHANGE ORDER#32 0001360 PC 36R4 Column Encasement East $27,521.00 $27,521.00 $0.00 $0.00 $27,521.00 100.000 $0.00 $0.00 0001380 CHANGE ORDER#33 0001390 PC 36R4 Column Encasement West $28,000.00 $28,000.00 $0.00 $0.00 $28,000.00 100.000 $0.00 $0.00 0001410 CHANGE ORDER#34 0001420 PC 43R1 Slab Openings $1,414.00 $1,414.00 $0.00 $0.00 $1,414.00 100.000 $0.00 $0.00 0001440 CHANGE ORDER#35 0001450 PC 45R1 Saw Cutting of Foundation Wall $1,419.00 $1,419.00 $0.00 $0.00 $1,419.00 100.000 $0.00 $0.00 0001470 CHANGE ORDER#37 0001480 PC 42R1 -ASI#68 Columns Modifications $2,671.00 $2,671.00 $0.00 $0.00 $2,671.00 100.000 $0.00 $0.00 0001500 CHANGE ORDER#38 0001510 PC 51 Chipping Gutter Wall to 4' $1,784.00 $1,784.00 $0.00 $0.00 $1,784.00 100.000 $0.00 $0.00 0001530 CHANGE ORDER#39 0001540 PC 49 Locate Water Main Valve $1,447.00 $1,447.00 $0.00 $0.00 $1,447.00 100.000 $0.00 $0.00 0001560 CHANGE ORDER#41 0001570 Structural Steel Delay Settlement $50,000.00 $0.00 $50,000.00 $0.00 $50,000.00 100.000 $0.00 $0.00 $5,981,671.00 $5,918,893.00 $50,000.00 $0.00 $5,968,893.00 99.79% $12,778.00 $0.00 AIA DOCUMENT G703•APPLICATION AND CERTIFICATE FOR PAYMENT • 1992 EDITION • A1A4)• C1992 • THE AMERICAN INSTITUTE OF ARCHITECTS.1735 NEW YORK G703-1992 AVENUE,N.W.,WASHINGTON,D.C. 20009-5292 • WARNING: Unlicensed photocopying violates U.S.copyright laws and will subject the violator to legal prosecution. "This document has been reproduced electronically with the permission of The American Institute of Architects under License 97003 to Primavera Systems,Inc. Reproduction of this document without project specific information is not permitted.Contact The American Institute of Architects to verify the current version of this document and license status." . . WAIVER OF LiEN . The undersigned is the duly authorized officer of. Hagerman ronstn'ic-tion Corp+orAt-inn , general contractor? (Name of Company) subcontractor;materialman or other person furnishing the services, labor, material or equipment indicated below in,the construction of improvements upon real estate located in Hamilton County, State of •Indiana , commonly .. known as Carmel Performing Arts ;which real estate is owned byCarmPl RPCiPUI npmPnt . . ("Owner"). Center Commission iNC_ONSIDERATIONofthesumofFive milli,cn six him sixty nil-1p thnisarrl (right. hurried nine and 45/100 DOLLARS($ 5,669,809.45 ), receipt of which is hereby acknowledged,and in order to procure one or more payments • •for Services, labor,material or equipmentprovided in such construction,the Company does hereby waive, release and quit • claim in favor of the Owner of the real estate and the lender or lenders providing funds with which payment of construction costs is or is to be made,and their assigns,all liens or claim or right to liens upon the land or improvements above•described a which the Company may now have for services,labor,material or equipmentfumished in respect of such land or improvements to and including the date hereof. The undersigned warrants that the Company has not and will not assign any claim for payment nor any right to perfect a lien against the real estate, and that he has the right to execute this waiver and release of liens on behalf of himself(herself)and the Company. The undersigned further warrants and represents that the Company has the right to transfer and does hereby transfer title to ' the services, labor,material or equipment to the Owners or lenders named above in consideration of the payment received hereunder. The undersigned further states that the consideration received hereunder is the sole-consideration received by the Company for said services,labor,material or equipment furnished to date,and that the Company has neither received nor made any security interest,title retention interest or lien rights in the said services,labor,material or equipment other than that released and transferred hereby. • The material,labor,services or equipment furnished a're more particularly described in the affidavit for payment submitted of even date herewith. The undersigned further warrants and represents that the Company has complied with all prevailing wage requirements under applicable law or as may be set forth in the contract documents. WITNESS the execution hereof this 17th day of September 2010_ , . . ..,. .. .ILA-4A7°L-A-od2rW.A!-V--•,__, .. . . (Mhmo nnrl TtlAI . • Richard E. Sutorius, Secretary • Hagerman C:onstriirt i can C:nrporati on • • (Name of Company) State of Indiana , County of _ Allen • , , SS: Before me, the . undersigned, a Notary. Public in and for said County and State,personally appeared Richard E. Sutc-,ri us , the secretary_ , of _ __�„ , • _ _ _ •_ ` who acknowledged (Title) (Name of Company) the execution of the foregoing Waiver of Lien on behalf of such Company and that the same is the free act and deed of such Company and the free act and deed of said officer. . • WITNESS my hand and notarial seal this 17th day of September , ,• 201n . . / My Commission Expires: `�� eCr6 • • c- • Notary Public iiin to 12/16/15 d tea'e ,6 av'w • . _. • :* 8' '• •r4 David C. Thomas My County of Residence: . , �,' ,,�, „y h• ,' ,o;',,....;en� ,,abaQ� • (Printed Name of Notary Public) Allen i, • U.S. DEPARTMENT OF LAnOR • '•'� .. PAYROLL AYROLL form nnroved WALE AND IIOUR DIVISION Budiel Bureau No. 44-111093 • • (For Contractor's'Optional Use;See Instruction, Form WH-347 Inst.) NAME OF CONTRACTOR 0 OR BUBCON RACTOR 1 ADDRESS Harman Construction Corporation P.O. Box 10690, Fort Wayne, IN PAYROLL NO. . ���t I FOR WEEK ENDING P.�ROJE;T AAN�OCATION Taw PROJECT OR CONTRACT NO. "? rC4Jarmng t1f lJ CC Job #2613,x -2695 to ro on• H)DA AND DATE to (6)• fn (SI PI 2 DEDUCTIONS NET NAME,ADDRr.!!r'AND o WORK K—— TOTAL RATE• ono WNEES SOCIAL SECURITY NUMBER r, O —) —I� .'AMOUNT WITH. PAID CLA9SIfIGT10N 11) IIOUR! Or'PAY' TOTAL OF EMPLOYEE _ p. IIOUR9 WORKED EACII DAY EARNED FICA HOLDING . OTIf ER INDUCTIONS FOR WEEK • 0 0 ' o - • . .B 0 • • SEE i ' ACHED . 0 • B . . 0 • s. 0 s - 0 . s • s - 0 • . - B • FORM WN-!q (1/ES)- ronurniy sot. TS4—PURCIIASE THIS FORM DIRECTLY FROR; THE SUPT. OF DOCUMENTS . • • . r f Di • .•J/AL .�) _ I a contract have been or will be made to appropriate programs for the benefit of such employees,except as noted In Section 4(c)below. )' >�'HPIS?9 �urOCt�i«S SN (b) WHERE FRINGE BENEFITS ARE PAID IN CASH {name or signatory patty/ ) do hereby state; 0 —Each laborer or mechanic listed In the above referenced payroll has been paid. as Indicated on the payroll, an amount not less than the sum of the applicable basic (1)That'I pay or supervise the payment of the persons employed by_Hagerman hourly wage rate plus the amount of the required fringe benefits as listed In the contract,except as noted In Section 4(c)below: Construction Corp. onthe C.rmel Performing rt-� (Contractor or subcontracted (Building or t rorq r II-S> `•(c) EXCEPTIONS Center ;that during the payroll period co me.clog on the ° `�- 0I / a EXCEPTION (CRAFT) EXPLANATION• day •-- '1►i 18 and ending t �o , /. . 0! si• all persons a. .toyed on said project hove been paid the full weekly.wages a rued,that no rebates ' have been or ill be made either directly or Indirectly to or on behalf of said Hagerman Construction Corporation from the full (Contractor or subcontractor) - - weekly wages earned by any person and that no deductions have been made either directly or Indirectly from the lull wages earned by any person, other then permissible deductions as defined In Regulations. Pert 3 (29 CFR Subtitle A), Issued by.the Secretary of Labor under the Copeland Act,as amended (48 Stet.948,63 Stat. 108,72 Slat,967;76 Stat.357,40 U.S.C.276c),and de- scribed below: . • REMARKS . (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and•complete,,that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination Incorporated Into the contract;that the classifications sot forth therein for each laborer or mechanic conform with the work he performed. (3) That any appranllces employed In the above period are duly registered In • bons fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training,United States Department of Labor,or If no such recognized agency . exists In a Stele,are registered with the Bureau of Apprenticeship and Training,United States Depart• meet of Labor. (4) That HAUL AND TITLE -- e. (AT 'E a • (a) WIIERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS ���.14. --+ '141hypi�ia THE•WII FUL FALSIFICATION 0 ANY OF THE oVE STATEMENTS MAT SUBJECT THE CONI;RACTOR —In addition to the basic hourly wage rates paid to each taborer or mechanic OR 'BUBCONIRACTOR'70 CIVIL OR CRINII(AL PROLECU110H. SEE SECTION 1001 Of TITLE )s AND listed In the above referenced payroll, payments of fringe benefits as listed In the SF�GTIOH 231 of T17LE 11 OF THG uHITEO.eTATES CODE ft Hagerman Construction Corp Certified Payroll Report 09-02-2010 Page 3 For the Period Ending: 08-29-10 Job:08-2613- Carmel Reg Performing Arts Cen • 211 CITY CENTER DRIVE CARMEL, IN 46032 r /BOYD D CHESTNUTT • a 2-'- 7972 S 250 E "` MARKLEVILLE, IN 46056 08-23 08-24 08-25 08-26 08-27 08-28 08-29 Total Cash Hrly Gross Total FWH SWH Other 527-11-1118 Caucasian Male Mon Tue Wed Thu Fri Sat Sun Hours Rate Fringe Fringe This Job Gross FICA SUI/SDI Deducts Net I - 0 Cement Mason Reg 8.00 8.00 16.00 26.80 428.80 1,554.40 302.66 52.85 235.19 844.79 428.80 118.91 CAMERON M JACKSON 216 W NORTH ST #3 LEBANON, IN 46052 08-23 08-24 08-25 08-26 08-27 08-28 08-29 Total Cash Hrly Gross Total FWH SWH Other 316-66-2538 Caucasian Male Mon Tue Wed Thu Fri Sat Sun Hours Rate Fringe Fringe This Job Gross FICA SUI/SDI Deducts Net S - 2 Cement Mason Reg 8.00 8.00 25.25 202.00 202.00 5.56 38.82 142.17 202.00 15.45 Totals for Carmel Reg Performing Arts Cen 08-23-10 08-24-10 08-25-10 08-26-10 08-27-10 08-28-10 08-29-10 Total Gross Total Monday Tuesday Wednesdy Thursday Friday Saturday Sunday Hours This Job Gross Deductions Net 8.00 8.00 .00 .00 8.00 .00 .00 24.00 630.80 1,756.40 FW8 302.66 986.96 FICA 134.36 SWH 58.41 SDI .00 Other 274.01 • 08-2613-A Hagerman Construction Corp. P 0 Box 10690 Fort Wayne, IN 46853-0690 STATEMENT OF COMPLIANCE Week Ending: 08-29-2010 (Certification Report Form WH-347) Carmel Reg Performing Arts Cen I, Richard E. Sutorius (Name of signatory party) , Secretary (Title) do hereby certify under penalty of perjury: (1) That I pay or supervise the payment of the persons employed by Hagerman Construction Corp. on the Carmel Reg Performing Arts Cen; that during the payroll period commencing on the 23 day of August 2010, and ending the 29 day of August 2010, all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Hagerman Construction Corp. from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357; 40 U.S.C. 276c), and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) T at: WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS: Secretary j,L. ./. 1_:: .I Richard E. Sutorius THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED STATES CODE. • U.S. DEPARTMENT OF LAROn PAYROLL Form App,ov.d. WALE AND DOUR DIVISION Budget Bun.0 No. 44-111093 • (For Contractor's'Optional Use;See Instruction, Form WH-347 Inst.) NAME OF CONTRACTOR 0 on BuecoNrnACTDn IN ADDRESS Hagerman Construction Corporation P.O. Box 10690, Fort Wayne, IN 468 3 PAYROLL NO. ) 176 _ I FOR WEEK ENDING - PROJECT AND LOCATION PROJECT OR CONTRACT NO. /rJ� �� CC.Job #2613/#2695 (I) (1) CD. F (u 0 AND DATE _ (S) (s)• m no (9) GROSS „ DEDUCTIONS 11�WORK SOCIAL SECURITY'NUMBER z CLASS FICTION o IIOUn3 WO�K�GCII DAY EARNED HOURS OF A O NT TAX. OEOUC ONT PAID s OF EMPLOYEE £ FH GRNED ►ICA IIOLDINO OTHER FOR WEEK O . 0 ' :1• .. * . . .. ... , • . O . • O s • S E ATTACHED 0 B . 0 s 0 s - • 0 • . e o__=— I — — s 0 . _ • roRU wN-SIT NJCs)- roRMEnLY SOL 184—PURCHASE Tills FORM DIRECTLY FRO? THE SUPT. OF DOCUMENTS . . . • e'+ ��-�/[1.� ` J/ contract have been or will be made to appropriate programs for the benefit of such Dolt c?� D < employees,except as noted In Section 4(c)below. Mains of signatory party) Inu\ (b) WHERE FRINGE BENEFITS ARE PAID IN CASH do hereby state: 0 —Each laborer or mechanic listed In the above referenced payroll has been paid, as • Indicated on the payroll, an amount not lass than the sum of the applicable basic (1)That I pay or supervise the payment of the persons employed by__Hagerman hourly wage rate plus the amount of the required fringe benefits as listed In the contract,except as noted In Section 4(c)below. Construction Corp. °n um Carme Ps forming Arts . • (Contractor or subcontractor) • (Bullding or work) 2 ,..„,11 ';'.(c)- EXCEPTIONS - Center •that during the payroll period commencing on the - )� 'S:_T ' - c���r��rv��.p� �j ._ / o Ol D EXCEPTION (CRAFT) • EXPLANATION •• day of,�1L1 _I �„ and ending that�—de' . I.--..,�/. • ' '..=..: all persons omotloyed on said project have been paid the full weekly wag.s earned,that no rebates .--. have been of wii I be made either directly or indirectly to or on behalf of said . Hagerman Construction Corporation Iron,the full ' • (Contractor or subcontrac(or) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the lull wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), Issued by.the Secretary of Labor under the Copeland Act.as amended (48 Stat.948,63 Stat. 108.72 Stat.967;76 Stat.357;40 U.S.C.276c),and de- scribed below: . . .• • REMARKS • (2) That any payrolls otherwise under this contract required to be submitted for the above - period are correct and complete;.that the wage rates for laborers or mechanics contained therein - - - are not less than the applicable wage rates contained In any wage determination Incorporated Into " - the contract;that the clessl8cations set forth therein for each laborer or mechanic conform with the . - " work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered wilts • S(ate apprenticeship agency recognized by the Bureau , of Apprenticeship and Training,United Stales Department of Labor,or II no such recognized'agency - exists In a Stele,are registered with the Bureau of Apprenticeship and Training,United States Depart• ment of Labor. •(4) That: NAME AND TITLE : SIDI�RE • • (n) WIIERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS C��'r`'�K2 �l,t`T"�i:'�l�+L�<C a l /�._%./..4 , ^'� I A i THE;WM FUL FALSIFICATION OF ANY OF'THE AO E aTATEMENTS MAY suencr THE CONTRACTOR —In addition to the basic hourly wage rates paid to each laborer or mechanic . "OR 'BUBCONIMCTOR'TO CIVIL OR CRIMINAL PROIECUlION. BEE SECTION 1001 OF BILE la AND listed In the above referenced payroll, payments of fringe benefits as listed In the gEGi7DN 331 OF 17TLE 1t uF THE UNITED.etATES CODE. i. . )•,ro,.,• n4-.a1V . ., - ' . Hagerman Construction Corp Certified Payroll Report 09-09-2010 Page 5 For the Period Ending: 09-05-10 Job:08-2613- Carmel Reg Performing Arts Cen • 211 CITY CENTER DRIVE CARMEL, IN 46032 V -� "1 L, 4.1 BOYD D CHESTNUTT C� 7972 S 250 E MARKLEVILLE, IN 46056 08-30 08-31 09-01 09-02 09-03 09-04 09-05 Total Cash Hrly Gross Total FWH SWH Other 527-11-1118 Caucasian Male Mon Tue Wed Thu Fri Sat Sun Hours Rate Fringe Fringe This Job Gross FICA SUI/SDI Deducts Net S - 0 Cement Mason Reg 8.00 8.00 16.00 26.80 428.80 1,072.00 177.01 36.45 181.08 595.45 428.80 82.01 Totals for Carmel Reg Performing Arts Cen 08-30-10 08-31-10 09-01-10 09-02-10 09-03-10 09-04-10 09-05-10 Total Gross Total Monday Tuesday Wednesdy Thursday Friday Saturday Sunday Hours This Job Gross Deductions Net .00 .00 8.00 8.00 .00 .00 .00 16.00 428.80 1,072.00 FWH 177.01 595.45 FICA 82.01 SWH 36.45 SDI .00 Other 181.08 4 08-2613-A Hagerman Construction Corp. °' P 0 Box 10690 'k Fort Wayne, IN 46853-0690 STATEMENT OF COMPLIANCE Week Ending: 09-05-2010 (Certification Report Form WH-347) Carmel Reg Performing Arts Cen I, Richard E. Sutorius (Name of signatory party), Secretary (Title) do hereby certify under penalty of perjury: (1) That I pay or supervise the payment of the persons employed by Hagerman Construction Corp. on the Carmel Reg Performing Arts Cen; that during the payroll period commencing on the 30 day of August 2010, and ending the 5 day of September 2010, all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Hagerman Construction Corp. from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357; 40 U.S.C. 276c) , and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4 That: WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS _ In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH _ Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS: Secretary •w „'A T A 4 ♦�C,-� Ric Ord E. Sutorius THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED STATES CODE. • - PAYROLL CERTIFICATION PROJECT NO. HCC Job #2613 #2695 I CERTIFY THAT THE PAYROLL RECORDS FOR Hagerman. Construction Corporation (Contractor) PAY PERIOD FROM TO g dak, ARE.TRUE AND CORRECT, TO THE BEST OF MY KNOWLEDGE AND BELIEF AND THE WAGE SCALE AS REQUIRED BY I.C. 5-16-7-1 HAS BEEN ADHERED TO. STATE OF Tom.-; na ) ) SS: COUNTY OF . A11Pn ) BEFORE ME, THE UNDERSIGNED, A NOTARY PUBLIC, PERSONALLY APPEARED ( (Z1 itS 5'-L , WHO (Name) (Tide) ACKi.NOWLEDGED EXECUTION OF THE ABOVE CERTIFICATION THIS ) 7 DAY OF _� �+W.11,.,1 i D albrr .°s.iC' bery p f;j -d�y o NOTARY PUBLIC (Signature) ®®® i it'th�e ?.4% Nor .*C:^W10 �` David C. Thomas T6* • NAME (Printed) MY COMMISSION EXPIRES: RESIDING IN Allen COUNTY 12/16/15_ REV 2/98 5 S.OBC-7 Q Gre ,5 i7� Ti a CV ` r3 >1 � F : w°c Monthly Employment Utlflzation Report -U.S. Department of Labor Employment Standards Administration 4� , • Office of Federal Contract Compliance Programs . This report Is required by Executive Order 11246,Sec.203.Failure to report can result In contracts 1. Covered Area(SMSA or EA) 2. Employers I.D.No. OMB No. 1215-0163 being cancelled,terminated or suspended In whole or in p art and the contractor may be declared Expires: 12/31/92 ineligible for further Government contracts of federally assisted construction contracts:- Hami 1 ton • 3c-Q813400 - • 3. Current'Goals 4. Report g P: led Name and Location.of Contractor Federal ' D Agency Box 10690 Hagerman Construction Corporation Funding Minority From- 4 Agency Y Female = To ;F-1_17- Fort Wayne, IN 46853 5. . - . 6. TOTAL FEDERAL& NON-FEDERAL CONSTRUCTION WORK HOURS 9. 10. 6a. 6b. :_ 6c. 6d. 6e. 7. 8. CONSTRUCTION Total All Black Asian or American Total Total Number Classifications Number of of.Minority TRADE,. Employees (Not of Hispanic ' Pacific Indian or Employees Employees By Trade Origin).` Hispanic Islander Alaskan Native Minority Female Percentage Percentage M F . M. F M F M F --- - — F M- F -- M F M Journey Worker :. �_ . Appreutlqu _ �_. . _-- -- .__- . _—. .__._ . ----Trainee . . .. Sub-Total : :::::::::•: •::: :: :::::: ::•:::•::::::::::::::.• :::•::::::::::: •, Journey Worker _ :: Apprentice Trainee MM.." � ::::•:::::::::-:::•::: .:•:::: .:::: .-::: :: :•:::--;: ::::•:::::•:::•::::,•.:::•:::::•::•::.::. . ::•::::::::.:•::•::::•:::::.mm ... ......................-..........sub-Total .... ..... . ........ . Journey Worker: . Apprentice SEE ATTACHED Trainee = S ub-Tot ... Journey Worker M 1 • Apprentice ___ Trainee ______ Sub-Total - Journey Worker Apprentice M__ Trainee ®_ ......... .--. ... ... -.. .. . ...................... .............. ... . 'Sub-Tot al . . _. .._......... .......................... ..... • Total Journey Workers onann Total Apprentices Total Trainees i GrandTotal . ... .......................... .... . .. .. ... ... .. ... . . .. . ........... ....................................... ..... . ... ..... 11. Compa. Off cial' Sign• and Title fly_ 12. Telephone Number 13. Date Signed Page 6( // �,. i (Include area code) c_ � of Q�,, 0C"�� itraZI i zS . 2cr Y (260) 424-1470 - /j Yf/j i 7 1v k Form rr_9F7 Monthly Employment Utilization Report Page 8 U.S. Department of Labor, Form CC-257 System Date: 08-25-2010 • -' Reporting Period: 07-26-10 to 08-22-10 . - Job# 082613A - Carmel Reg Performing Arts Cen County: CO Total All Employees Asian/ American Indian/ Total Minority \Construction By Trade Black Hispanic Pacific Islander Alaskan Native Minority Female Employees Employees Trade Class Male Female Male Female Male Female Male Female Male Female % % M F M F Cement Mason Journeyman 36.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 2 0 0 0 Sub-total 36.00 .00 .00 .00 .00 .0 .0 Laborer Journeyman 4.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 1 0 0 0 Sub-total 4.00 .00 .00 .00 .00 .0 .0 Job Totals 40.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 3 0 0 0 • `- ' U.S. DEPARTMENT OF LAROn .< PAYROLL Form *pproved. WALE AND HOUR DIVISION Budget Buneu No. 44-n1093 • • (For Contractor's•Optional Use;See Instruction, Form WU-347 Inst.) NAME OF CONTRACTOR u OR SUBCONTRACTOR 91 ADDRESS • Hagerman Construction Corporation P.O. Box 10690, Fort Wayne, IN 468 3 PAYROL HO. --r FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. 1l r ...Air •�•B •�,.L�•• t_ !=•1 C.Job #261 /#3595�9, (I) rn Dn. FF.. (4)DAY D DATE t!) te)' m (5) • I_ N - DEDUCTIONS NAMF,ADDRES5.-AND WORK ——— TOTAL RATE •ORO!! HET SOCIAL SECURITY NUMBER o 1—I AMOUNT WITH• WAGES `a CLASSIFICATION - HOUR! Of'►AYE EARNED FIG IIOLDINO OTHER TOTAL PAID 11 OF EMPLOYEE • _ F '— 0[000TIORT o o IIOlIR9 WORKED EACH DAY TAX. TOR WEEK O • II . • . 0 _ - 8 0 a . , ATTACHED — 0 • • . a . . O a o . . . . • S . 0 • a .. 0 • S • 0 • - s FORM WH-]4r Nose)— FORMERLY SOL Teo—PURCHASE THIS FORM DIRECTLY FRO? THE SUPT. OF DOCUMENTS • • • r Date - %i��)ma �(I ���) n contract have been or will be made to appropriate programs for the benefit of such 1. employees,except as noted In Section 4(c)below. MIAMI,Vr .alma,.., ,..,,r, .) . (b) WHERE FRINGE BENEFITS ARE PAID IN CASH do hereby state: ✓ El —Each laborer or mechanic listed In the above referenced payroll has been paid, as • . Indicated on the payroll, an amount not less than the sum of the applicable bask • (1)That'I pay or supervise the payment of the persona employed by. Hagerman hourly wage Ile plus the amount of the required (rings benefit, as listed In the contract,except as noted In Section 4(c)below: Construction Corp. on the Carme Performing Arts • •• • (Contractor or subcontractor) •• '•• (eulwina or work) ';',.(o)' EXCEPTIONS . • Center • ; that during the.payroll period commencing on the 11n eRDrD yT 1 010 EXCEPTION (CRAFT) EXPLANATION• day • . _. ire •0• and ending th dday• .. . ►-A 4V'::OA • . . all parsons .r played on said project hove been paid the full weekly.wages ,••med,that no rebates • • . .. • . . have •been o Ill be made either directly or Indirectly to or on behalf of said . • • Hagerman Construction Corporation from the full '• . (Contractor or■ubcont,sclor) .. • . week ly wages earned b g by any parson and that no deductions have been made either directly or - •Indirectly from the lull wages earned by any person, other then permissible deductions as defined • In Regulations, Part 3 (29 CFR Subtitle A), Issued by.the Secretary of Labor under the Copeland Act,as emended(48 Stat.948,63 Stat. 108,72 Stat.967;76 Stat.357;40 U.S.C.276c),end de- scribed below: . . .. • • REMARK'S . . . . (2) That any payrolls otberwla• under title contract required'to be submitted for the above . • - period are correct and.complete;_that the wage rates for laborers or mechanics contained•therein . • . are not less than the applicable wage rates contained In any wage determination Incorporated Into • ' " the contract;that the clesslfications set forth therein for each laborer or mechanic conform with the •. - • work he performed. (3) That any apprentices employed In the above period are duly registered in • bona Ilde apprenticeship program registered with a State apprenticeship agency recognized by Ute Bureau ' of Apprenticeship and Training,United States Department of Labor,or II no such recognized'agency • . exists In a Stele,are registered with the Bureau of Apprenticeship and Training,United States Depart. • ment of Labor. (4) That: •• NAME AND TITLE •• e10 rT1 URE / j .• • (a) WIIERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS n S I/I.!`' ( l��l gCIXi) THE!INN TM. FALSIFICATION OF ANY OF'Tr1E A.• E STATEMENTS MAY SUBJECT THE CONTRACTOR AR —In addition to the basic hourly wage rates paid to each laborer or mechanic _ 'On 'EUECONTRACTOR'10 CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE le AND listed in time above referenced payroll, payments of fringe benefits as listed in the SECTION Zit OF TITLE Al OF THE UNITED.a IATES CODE. .'1• . Jill.,• •V,a,44 .. o Hagerman Construction Corp Certified Payroll Report 08-25-2010 Page 4 For the Period Ending: 08-22-10 Job:08-2613- Carmel Reg Performing Arts Cen . 211 CITY CENTER DRIVE CARMEL, IN 46032 BOYD D CHESTNUTT //1 4 7972 S 250 E MARKLEVILLE, IN 46056 08-16 08-17 08-18 08-19 08-20 08-21 08-22 Total Cash Hrly Gross Total FWH SWH Other 527-11-1118 Caucasian Male Mon Tue Wed Thu Fri Sat Sun Hours Rate Fringe Fringe This Job Gross FICA SUI/SDI Deducts Net S - 0 Cement Mason Reg 8.00 8.00 16.00 26.80 428.80 958.10 148.54 32.58 170.68 533.00 428.80 73.30 Totals for Carmel Reg Performing Arts Cen 08-16-10 08-17-10 08-18-10 08-19-10 08-20-10 08-21-10 08-22-10 Total Gross Total Monday Tuesday Wednesdy Thursday Friday Saturday Sunday Hours This Job Gross Deductions Net .00 8.00 8.00 .00 .00 .00 .00 16.00 428.80 958.10 FWH 148.54 533.00 FICA 73.30 SWH 32.58 SDI .00 Other 170.68 f. 08-2613-A Hagerman Construction Corp. P 0 Box 10690 Fort Wayne, IN 46853-0690 STATEMENT OF COMPLIANCE Week Ending: 08-22-2010 (Certification Report Form WH-347) Carmel Reg Performing Arts Cen I, Richard E. Sutorius (Name of signatory party), Secretary (Title) do hereby certify under penalty of perjury: (1) That I pay or supervise the payment of the persons employed by Hagerman Construction Corp. on the Carmel Reg Performing Arts Cen; that during the payroll period commencing on the 16 day of August 2010, and ending the 22 day of August 2010, all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Hagerman Construction Corp. from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A) , issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357; 40 U.S.C. 276c) , and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS: Secretary Richard E. Sutorius THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED STATES CODE. •• ta;^ • U.S, DEPARTMENT OF LABOR ' r.z ._ PAYROLL Form lIpprovd. WALE AND HOUR DIVISION BlydQet Durum No. 44-111091 • (For Contractor's Optional Use;See Instruction, Form WH-347 Inst.) • NAME OF CONTRACTOR O OR SUBCONTRACTOR ADDRESS Hagerman Construction Corporation P... B.x 86•0 A_ As- 1R PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO. � ��%D P Otirling Arts C nb2r CC.Job #2Erl3/#�26 (1) (2) CO 1. HI o Y AND DATE cs► let• In rot NI• » DEDUCTIONS IIET NAME,ADDRESS.AND a WORK er—————— TOTAL RATE• GROSS WAGES • SOCIAL SECURITY NUMBER `o O nouns ' • "MUM. CLASSIFICATION OUR9 OF-PAY' • TOTAL OF EMPLOYEE a i O. IIOURS WORKED EACII DAY EARNED FICA IIOT NO OTHER DEDUCTIONS FOR WEEK • 0 • • • . . 0 • • . .a 0 . 11 • SFF A ,CHFD , • • o . B o • S . . •II . . . . 0 S . . 0 . • S - . 0 roRu wlt-sir (1/6e)- FORMERLY Sot. let—PURCHASE THIS FORM DIRECTLY PROM THE SUPT. OF DOCUMENTS . a . Dale_ 11/01 . [ /; `b1 0 contract have been or will be made to appropriate programs for the benefit of such �� ,6_ �• �•�,�� �© employees,except as noted In Section 4(c)below. I, / 3ot 11J•�"It' _mac in,>i,a or rianalory party) pitta (b) WHERE FRINGE BENEFITS ARE PAID IN CASH do hereby state: 0 —Each laborer or mechanic listed In the above referenced payroll has been paid. as Indicated on the payroll, an amount not less than the sum of the applicable basic (1)That l pay or supervise the payment of the persona employed by oar erman hourly wage rate plus the amount of the required fringe benefits as llsled In the contract,except as noted In Section 4(c)below. Construction Corp. on the C_rmel P- forming Ar s (Contractor or subcontractor) founding or trod() i -(c) EXCEPTIONS Center that during the payroll perod mme Ing on the �)0 �/© EXCEPTION (CRAFT) EXPLANATION ) day o A. . • . •.40 and ending the Gday.111 -Awl) . . all persons Om. .yed on said protect hove been paid the full weekly wages •1= ed,t at no iebetss S have been or w be made either directly or Indirectly to or on behalf of said . ' Hagerman Construction Corporation from the full ' (contractor or subeontreNOr) - weekly wages earned by any person and that no deductions haVe been made either directly or Indirectly from the lull wages earned by any person, other than permissible deductions as defined In Regulations. Part 3 (29 CFR Subtitle A), issued by.the Secretary of Labor under the Copeland Act,as amended (48 Slat,948,63 Stet. 108,72 Stet,967;76 Stet.357;40 U.S.C.276c),sod de- scribed below: .- REMARKS •' . ' . . (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and•complete; that the wage rates(or laborers or mechanics contained'therein V . era not less than the applicable wage rates contained In any wage determination Incorporated Into • the contract;that the ciossifications sot forth therein for each laborer or mechanic conform with the work he performed, • (3) Thal any apprentices employed in the above period ere duly registered In a bona fide apprenticeship program registered with a Slate apprenticeship agency recognized by the Bureau _ of Apprenticeship and Training,United States Department of Labor,or if no such recognized agency ' exists In a Stele,are registered with the bureau of Apprenticeship and Training,United States Depart• . ment of Labor, • (4) Thal: E AND TITLE SION E . om` (a) W E RE FRINGE UENEFITS ARE PAID TO APPROVED PLANS, FUND S, O R PROGRAMS ����T )�5 fL.JIdI� u.'∎4 TIIE:worm. rALSIFICATION or ANY OF TIME A OVa STATEMENTS MAY SUBJECT 1HE CONtRACTOR —In addition to the basic hourly wage rates paid to each laborer or mechanic OR SUFICONIRACTOR'10 CIVIL OR CRIMINAL '• ELUTION. SEE SECTION 1001 OF TULE IS ANS listed In the above referenced payroll, payments of fringe benefits as listed In the =non 231 OF TITLE 31 OF THE UNITED STATES CODE. I. . 1•,9n,,. 114-W4 i il . 1 P -- lk '€w,4. �t`kr "� 1, 11 Construction Corp Certified Payroll Report 08-18-2010 Page 6 ce 7'x-1-r e 1L1,: For the Period Ending: 08-15-10 " rt t .•613- Carmel Reg Performing Arts Cen 1*r',;,,r1 CITY CENTER DRIVE ` l ° ' EL, IN 46032 `' - � ._ CHESTNUTT 7972 S 250 E MARKLEVILLE, IN 46056 08-09 08-10 08-11 08-12 08-13 08-14 08-15 Total Cash Hrly Gross Total FWH SWH Other 527-11-1118 Caucasian Male Mon Tue Wed Thu Fri Sat Sun Hours Rate Fringe Fringe This Job Gross FICA SUI/SDI Deducts Net S - 0 Cement Mason Reg 8.00 8.00 26.80 214.40 1,072.00 177.01 36.45 186.52 590.02 214.40 82.00 Totals for Carmel Reg Performing Arts Cen -- 08-09-10 08-10-10 08-11-10 08-12-10 08-13-10 08-14-10 08-15-10 Total Gross Total Monday Tuesday Wednesdy Thursday Friday Saturday Sunday Hours This Job Gross Deductions Net .00 .00 8.00 .00 .00 .00 .00 8.00 214.40 1,072.00 FWH 177.01 590.02 FICA 82.00 SWH 36.45 SDI .00 Other 186.52 4 03-2613-A Hagerman Construction Corp. P 0 Box 10690 Fort Wayne, IN 46853-0690 STATEMENT OF COMPLIANCE Week Ending: 08-15-2010 (Certification Report Form WH-347) Carmel Reg Performing Arts Cen I, Richard E. Sutorius (Name of signatory party), Secretary (Title) do hereby certify under penalty of perjury: (1) That I pay or supervise the payment of the persons employed by Hagerman Construction Corp. on the Carmel Reg Performing Arts Cen; that during the payroll period commencing on the 9 day of August 2010, and ending the 15 day of August 2010, all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Hagerman Construction Corp. from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357; 40 U.S.C. 276c), and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH _ Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS: Secretary 116.4 ,44 ,i`. A /.P/h_. .A Richa o E. Sutorius THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED STATES CODE. B i, . . . ' U.S. DEPARTMENT OF Mon .. PAYROLL ►oom Annrev.d. WALE AND HOUR DIVISION Budget eunau No. 44-111093 • (For Contractor's Optional Use;See Instruction, Form MI-347 Inst.) NAME OF CONTRACTOR ❑ OR SUBCONTRACTOR l ADDRESS Hagerman Construction Corporation P.O. Box ).0690, Fort- Wayne, IN 46853 PAYROLL NO. /•. _I FOR WEEK ENDING PROJECT AND LOCATION II PROJECT OR CONTRACT NO. D ' Arts i�CC.Job #2613/#2695 (I) rn en. HI DAY AND DATE (5) (6)• m rol (91 g rc N - DEDUCTIONS HET NAM[,ADDRfss,'AND a WORK K—--——I—I' TOTAL RATE•. GROSS WAGES SOCIAL SECURITY NUMBER O •AMOUNT WITH• PAID o CLASSIFICATION nouns OF"PAY TOTAL OF EMPLOYEE _ 0. HOURS WORKED EACH DAY EARNED FICA HOLDING OTHER OEDUCt10KT FOR WEEK - • O . a • - o • .s O S • SEE ATTACHED _ 0 . s . O • a O . • B - . . - • 0 B . •- D s O . . - S • • Eons WHa1T Hegel- FORMERLY sot. Igo—PURCHASE THIS FORM DIRECTLY FROM THE SUPT. OF DOCUMENTS . • • • • Dato— -R contract have been or will be made to appropriate programs for the benefit of such employees,except as noted In Section 4(c)below. 1, � �f�1t la) (b) WHERE FRINGE BENEFITS ARE PAID IN CASH do hereby stale: —Each laborer or mechanic listed In the above referenced payroll has been paid, as Indicated on the payroll, an amount not less than the sum of the applicable basic (1)Thet'I pay or supervise the payment of the persons employed by._$aT=T-rPA hourly wage rats plus the amount of the required (rings benefits pa listed In the contract,except as noted In Section 4(c)below: Construction Corp. on the C rme P-Ii:orming Art . (Contractor or subcontractor) ` (Building or wor10 `,`-(C) EXCEPTIONS Center •that during the payroll period Comm ncing on the QP/O jam— 1 • EXCEPTION (CRAFT) EXPLANATION day •f+r ._.A- . ,elti • end ending th day' 1PP•O=,. Ali all persons • +ployed on said project have bean paid the full weekly-wage aed,that no rebates have been o III be made either directly or Indirectly to or on behalf of sal, m• . . Hagerman Construction Corporation from the full (Contractor or subcontractor) ' weekly wages earned by any person and that no deductions have been made either directly or Indirectly from the lull wages earned by any person, other than permissible deductions as defined In Regulations, Part 3 (29 CFR Subtitle A), Issued by.the Secretary of Labor under the Copeland Act,as emended(48 Stat.948,63 Slat. 108,72 Stat.967;76 Stat.357;40 U.S.C.276c),and de- scribed below: • REMARKS . (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete;-that the wage rates for laborers or mechanics contained therein - . are not less then the applicable wage rates contained In any wage determination Incorporated Into the contract;that the clessl8catlona sot forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed In the above period are duly registered In a bona fide apprenticeship program registered whir a State apprenticeship agency recognized by the Bureau • of Apprenticeship and Training,United States Department of Labor,or If no such recognized agency exists In a Stet:,are registered with the Bureau of Apprenticeship and Training,United States Depart• ment of Labor. (4) That: I/AML AND TITLE ; aloltA`•' -y�.'•1�r/�- Bfr(a) WHERE FRINGE BENEFITS ARE PAID TO Al'PROVED PLANS, FUNDS, OR PROGRAMS 4447 SIJ�T1lr'ITY1J--"`' 'IK' , J �,i 2..�/A�1 �}� TI/E WII rUL FALSIFICATION OF ANY OF'Tl1E AB - STATEMENTS MAY SUBJECT THE CONTRACTOR 14t! —In addition to the basic hourly wage rates paid to each laborer or mechanic 'OR 'doll N11iAC.tOR'TO dvtl OR CRIM11tAL PNOSECUiION. StE SECTION 1001 OF TITLE is AND IMO in the above referenced payroll, payments of fringe benefits as listed in the SEGT10t/z�l OF TITLE Dl OF THE UNITEO.arATES CODE, • ,. . .. ... i i Hagern o Com?truction Corp Certified Payroll Report 08-12-2010 Page 6 For the Period Ending: 08-08-10 Joi08-2613- Carmel Reg Performing Arts Cen ' 211 CITY CENTER DRIVE CANNEL, IN 46032 \ MICK L LEAS , 8924 S MAIN ST PETROLEUM, IN 46778 08-02 08-03 08-04 08-05 08-06 08-07 08-08 Total Cash Orly Gross Total FWH SWH Other 304-04-2317 Caucasian Male Mon Tue Wed Thu Fri Sat Sun Hours Rate Fringe Fringe This Job Gross FICA SUI/SDI Deducts Net S - 0 Cement Mason Reg 4.00 4.00 31.95 127.80 1,278.00 228.51 43.45 201.38 706.89 127.80 97.77 ROGER N SUMMERS . 114 S BLACK ST ALEXANDRIA, IN 46001 08-02 08-03 08-04 08-05 08-06 08-07 08-08 Total Cash Hrly Gross Total FKH SWH Other 304-82-3846 Caucasian Male Mon Tue Wed Thu Fri Sat Sun Hours Rate Fringe Fringe This Job Gross FICA SUI/SDI Deducts Net S - 0 Laborer Reg 4.00 4.00 21.61 86.44 799.57 108.91 27.19 41.97 560.34 86.44 61.16 Totals for Carmel Reg Performing Arts Cen 08-02-10 08-03-10 08-04-10 08-05-10 08-06-10 08-07-10 08-08-10 Total Gross Total Monday Tuesday Wednesdy Thursday Friday Saturday Sunday Hours This Job Gross Deductions Net .00 8.00 .00 .00 .00 .00 .00 8.00 214.24 2,077.57 FWH 337.42 1,267.23 FICA 158.93 SWIl 70.64 SDI. .00 Other 243.35 , 1 . 08-26:.3-A Hagerman Construction Corp. P 0 Box 10690 Fort Wayne, IN 46853-0690 STATEMENT OF COMPLIANCE Week Ending: 08-08-2010 (Certification Report Form WH-347) Carmel Reg Performing Arts Cen I, Richard E. Sutorius (Name of signatory party) , Secretary (Title) do hereby certify under penalty of perjury: (1) That I pay or supervise the payment of the persons employed by Hagerman Construction Corp. on the Carmel Reg Performing Arts Cen; that during the payroll period commencing on the 2 day of August 2010, and ending the 8 day of August 2010, all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Hagerman Construction Corp. from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357; 40 U.S.C. 276c), and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: ( HERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS: / I Secretary :I �: u�1I. ���A. Richard E. Sutorius THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED STATES CODE. • U.S. DEPARTMENT OF LABOR PAYROLL Form Approved WALE AND HOUR DIVISION y. Bucket Durum No. 44-01093 • (For Contractor's Optional Use;See Instruction, Form W11,347 Inst.) NAME OF CONTRACTOR u OR 9UBCOHTRACTOR ADDRESS Ha.erman Construction Co ..ration / P.O. Box 10690, Fort Wayne, TN 468 3 PATROL HO. /� FUR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO.• / M'•"-_ '� " •�•"'�•• CC.Job #2613/#2695 II) rn p). ()DAY AND DATE (9) (5) m rot (9) DEDUCTION! NAMF,AODRF.!!;AND o DROSS HET SOCIAL SECURITY NUMBER WORK TOTAL emir WAGES D — — AMOUNT WITII• PAID o CU1991►ICATIOH HOUR! or PAY' EARNED FICA 110LOIN0 OTHER TOTAL Of EMPLOYEE F '— DEDUCTIONS O. HOURS WORKED EACII DAY T FOR WEEK 0 • 0 . 0 • 8 - - 0 • B o • • B 0 — D 8 — D S U FORM WH-74T NM)- ronmrnLY sot. 194—PURCHASE THIS FORM DIRECTLY FROM THE SUPT. OF DOCUMENTS ' • • • • • •pat: _ ry(/ Q contract have been or will be made to appropriate programs tar the benefit of such employees,except as noted In Section 4(c)below. I. –.121P./1442.1.V..35;tta i Q C�J�✓7o-.. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH (Na of signatory party) G••..r do hereby slate: 0 —Each laborer or mechanic listed In the above referenced payroll hes been paid. as Indicated on the payroll, an amount not leas than the sum of the applicable basic (1)That'I pay or supervise the payment of the persona employed by. Hagp 1 an hourly wage rate plus the amount of the required fringe benefits as listed In the contract,except as noted In Section 4(c)below: Construction Corp. onuie Carme P-r orming Arts - • (Contractor or aubcgntradod •` (Building or wort° ,-_ - 'i'.(C): EXCEPTIONS . Center ;that during the payroll period mmencing on the (�) • °Z�)0 1 +' EXCEPTION (CRAFT) .EXPLANATION - day of and ending the.L_dey• ..—4 • -- .41.■ _ • _ . all persons employed o a d project kayo been paid the full weekly wage earned,that no rebates • have been or will be me ither directly or indirectly to or on behalf of said . Hagerman Construction Corporation from the full ' , (Contractor or aubconlnsctor) .. • weekly wages earned by any person arid that no deductions have been made either directly or Indirectly from the full wages earned by any parson, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), Issued by.the Secretary of Labor under the Copeland Act,as amended(48 Stat.948,63 Stat. 108,72 Stat.957;76 Stat.357;40 U.S.C.276c),And de- scribed below: . • REMARKS • (2) That any payrolls otherwise under this contract required to be submitted for the above . period are correct and complete; that the wage rates for laborers or mechanics contained therein . are not less then the applicable wage rates contained In any wage determination Incorporated Into the contract;that the clessificatlons set forth therein for each laborer or mechanic conform with the . • work lie performed. (3) That any apprentices employed In the above period are duly registered In a bona lids apprenticeship program registered with a State apprenticeship agency recognized by the Bureau • of Apprenticeship end Training,United Steles Department of Labor,or if no such recognized agency exists In a Siete,are registered with the Bureau of Apprenticeship and Training,United States Depart. ment of Labor. (4) That: SAND TITLE . aiouAT .I�e• . , _ t`_ •_ (-(/���������,.{f�� I Yom`."' (a) WIIERE FRIIIGE UENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS L' _ ��4L-•._ 4. I,•' TI/E:WIT FUL FALSIFICATION OF ANY OF'THE All .TATEMENTS MAY SUBJECT THE CONTRACTOR In addition to the basic hourly wage rates paid to each laborer Or mechanic -On -eleCONrhe070R'70 CIVIL OR CRIMINAL P': COTTON. BEE SECTION 100) Of TITLE le AND listed in the above referenced payroll, SEGION 2sl OF TITLE!1 of 7NE ORITED.STATES CODE p y payments of fringe benefits as listed In the •I• . I•rol,,• 1141,9p HI! 08.2613-A Hagerman Construction Corp. P 0 Box 10690 Fort Wayne, IN 46853-0690 STATEMENT OF COMPLIANCE Week Ending: 08-01-2010 (Certification Report Form WH-347) Carmel Reg Performing Arts Cen I, Richard E Sutorius (Name of signatory party) , Secretary (Title) do hereby certify under penalty of perjury: (1) That I pay or supervise the payment of the persons employed by Hagerman Construction Corp. on the Carmel Reg Performing Arts Cen; that during the payroll period commencing on the 26 day of July 2010, and ending the 1 day of August 2010, all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Hagerman Construction Corp. from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A) , issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357; 40 U.S.C. 276c) , and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4)/That: a HERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS: 1 7 Secretary - ■ .. A b. IIJMA r..J Richar• E Sutorius THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED STATES CODE. • • " ; PAYROLL CERITHCATION • • PROJECT NO. HCC Job #2613 ' #2695 I CERTIFY THAT THE PAYROLL RECQRDS FOR Rag'rerman Construction Corporation (Contractor) PAY PERIOD FROM -6741//r) TO Ip141111/0 ARETRUE AND CORRECT, TO • THE BEST OF MY KNOWLEDGE AND BELIEF AND THE WAGE SCALE AS REQUIRED BY I.C. 5-16-7-11 HAS BEEN ADHERED TO. STATE OF •Tnci.i_ana ) ) SS: COUNTY OF . Allen ) BEFORE ME, THE UNDERSIGNED, A NOTARY PUBLIC, PERSONALLY . . " . APPEARED , sec, &1st_ WHO V VVV• • •• • r5 (Name) V (Title) ACKNOWLEDGED EXECUTION OF THE ABOVE CERTIFICATION THIS /111Ay OF , .20/D. ■08.4#" .•-' V . . 416 ■.• .. 19/n. 14i .°47d3 ober-4/A(5) NOTARY PUBLIC (Signature) • *14.136'$i ift; "4511EAL F David C. Tho ma s 'o• 4"00110 .. ..4.**NP NAME (Printed) S.17S • . MY COMMISSION EXPIRES: V RESIDING IN Allen COUNTY 12/16/15_ • REV 2198 S.OBC-7 V Monthly Employment Utilization Report -U.S. Department of Labor Employment Standards Administration . ..e,.,- ---- Office ,. of Federal Contract Compliance Programs This report is required by Executive Order 11246,Sec.203.Failure to report can result In contracts 1. Covered Area(SMSA or EA) 2. Employers I.D. No. OMB No. 1215-0163 being cancelled,terminated or suspended In whole or In part and the contractor may be declared Expires: 12/31%92 Ineligible for further Government contracts of federally assisted construction contracts: Hami 1 tort " —0281 3400 ' 3. Current'Goals 4. Reporting Period Name and Location.of Contractor . " Federal Hagerman Construction Corporation Funding Minority '' From P.O. Box 10690 . . Agency Female : To LO O 0 Fort Wayne, IN 46853 .: . 5. • . 0. TOTAL FEDERAL& NON-FEDERAL CONSTRUCTION WORK HOURS 9. 10. . . • 6a. 6b. 6c. 6d. 6e. 7. 8. •CONSTRUCTION ' Total All. Black Asian or American Total Total Number Classifications Number of of.Minority TRADE,. Employees (Not of Hispanic Pacific Indian or Employees Employees By Trade Origin) : Hispanic Islander Alaskan Native Minority Female , ' Percentage Percentage M F. M. F F M F M F M ..--F Journey Worker :. _• Approntico ,.Trainee Sub-Tote. Journey Worker v — • Apprentice Trainee . t1-T tai Su o • Journey Worker: . - Apprentice SEE ATTACHED Trainee . . -•,- Joumey Worker Apprentice • ' Trainee • Journey Worker Apprentice ' Trainee • Sub-Total .. . • Total Journey Workers . Total Apprentices Total Trainees .• • i - Grand ....... ............. .. �...i... ................. � ....�.i.;.;.;.i....:.;.�.i...'......:..i.: .' �..... ......:.......i.....:..;?t � � �i:;s:�i ':i;�;iii:<;;iit :::�;si� i; ;;i ::::$,;:?is-;;; �;;sii;:; :?i.t;...s.;;i:si...s:..-.:i<:•a;ii :`�':'ri'tiirii.ih'/.%'i?:#�:i'i:•;; k;-;-�`2°;-;;;: :: r;� ii ;:;i::�:•;;:- 11. Company • lays .nat roe Tit 12. Telephone Number Date :: Page F— - (Include area code) of �,r. -,-e>7`rC.S n 21.�s, ' (260) 424-1470 - Fnrin Cr-9s7 Monthly Employment Utilization Report Page 7 U.S. Department of Labor, Porn CC-257 System Date: 06-24-2010 r Reporting Period: 05-24-10 to 06-20-10 Job# 082673A - Carmel Reg Performing Arts Cen County: CO Total All Employees Asian/ American Indian/ Total Minority \Construction By Trade Black Hispanic Pacific Islander Alaskan Native Minority Female Employees Employees Trade Class Male Female Male Female Male Female Male Female Male Female % % M M F u,, ".s 3 a trN., _A Carpenter Journeyman 34.50 .00 .00 .00 .00 .00 .00 .00 .00 .00 1 0 0 0 r Sub-total 34.50 .00 .00 .00 .00 .0 .0 ' '` ' Cement Mason Journeyman 40.00 .00 16.00 .00 .00 .00 .00 .00 .00 .00 2 0 1 0 77 Sub-total 40.00 16.00 .00 .00 .00 40.0 .0 ,,, _ Laborer Journeyman 58.50 .00 .00 .00 .00 .00 .00 .00 .00 .00 1 0 0 0 ��.V Sub-total 58.50 .00 .00 .00 .00 .0 .0 z � ' Job Totals 133.00 .00 16.00 .00 .00 .00 .00 .00 .00 .00 4 0 1 0 ,4 `'i', f 3 t .', F ks 11.1 k , 4p yr� rorgfp reigrMO ,may FY ! isEt ire$,;. 0410 .iz t (F f po.V 4 k S 7 1st w I' '-- S U.S. DEPARTMENT OF ERROR • PAYROLL Form Approved. WACE AND HOUR DIVISION Budget Donau No. 44-RI09) • (For Contractor's Optional Use;See instruction, Form WH-347 Inst.) NAME OF CONTRACTOR ❑ OR SUBCONTRACTOR , ADDRESS Harman Construction Corporation P.O. Box 10690, Fort Wayne, IN 468 3 PAYROLL NO. i J I FOR WEEK ENDING /o 15 r� PROJECT�.' AND LOCATION Arts PROJECT OR CONTRACT NO. �. I I ( l.[rrre. Ft*forming rrts CC.Job #2613/#2595 to rn M. FF.. (4)DAY 0 DATE En M' m rot 191 N DEDUCTION! HET NAME,ADDRF.SS,•AND WORN r),__________._______. TOTAL RATS GROSS WAGES SOCIAL SECURITY NUMBER AMOUNT WITH. PAID o CLASSI►ICAIION IIOUR9 O►'PAY [ARNED FICA IIOLDINO OTIIER • TOTAL of EMrLOYEE F DEDUCTIONS O ilOUR3 WORKED EACH DAY TAX FOR WEEK 0 . 9 • . O S 0 S • S E ATTACHED 0 B • . . o • • • s. O • . S . . 0 . S . .. • 0 . • s 0 B roRU WII-517 (1166)- FORMERLY en Tet—PURCHASE THIS FORM DIRECILY FRO?; THE SUPT. OF DOCUMENTS • • • , • Dale " r /� t.4 �. JC/ contract have been or will be made to appropriate programs for the benefit of such employees,except as noted In Section 4(c)below. I. —""6, a,y P;„y) "'ale) (b) WHERE FRINGE BENEFITS ARE PAID IN CASH do hereby state: • —Each laborer or mechanic listed In the above referenced payroll has been paid. as • • Indicated on the payroll, an amount not lass then the sum of the applicable basic (1)That pay or supervise the payment of the persona employed by. H ••-marl hourly wean rate plus the amount of the required fringe benefits as listed In the ' contract,except as noted In Section 4(c)below: : Construction Corp. on the Came Pe forming Arts •• ' . . • • (Contractor or subcontractor) . '• (Building or wed) ,..(c)• EXCEPTIONS - . • Center ; that during the.payroll period comma clna on the / ” .• ' • • • � rT art� ) EXCEPTION (CRAFT) E)(PLANATION• day of �, pF>iFY�„ and ending tit day i all persons employed on said project hove been paid the full weekly.wages earned,that no rebates i . .. • • have been of will be made either directly or Indirectly to or on behalf of said . • ' • Hagerman Construction Corporation Iron the loll ' • (Contractor or■ubcooln tor) .. . weekly wages earned by any person and that no deductions have been made either directly or Indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), Issued by.the Secretary of Labor under the Copeland Act,as amended (48 Stat.948,63 Slat. 108,72 Stat.967;76 Stat.357;40 U.S.C.276c),and de- scribed below: . • • . .. REMARKS . •' • . . (2) That any payrolls otherwise under this contract required•to be submitted for the above ' .- ' . • • . • . .• ••• - period are correct and.complete;.that the wage rates for laborers or mechanics contelned•thmin . are not less than the applicable wage rates contained In any wage determination Incorporated Into . the contract;that the classifications set forth therein for each laborer or mechanic conform with the • . • • work he perforated. • (3) That any apprentices employed In the above period are duly registered In a bona lido apprenticeship program registered with a Siete apprenticeship agency recognized by Ito Bureau of Apprenticeship and Training, United States Department of Labor,or If no such recognized'agency •• exists In a Stele,are registered with the Bureau of Apprenticeship and Training,United States Depart. . ment of Labor. (4) That: • ISAAME AND TITLE ( 010NATU _ - /. `_ '• • (u) WIIERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS rl�?� i0,". ere0;, J!I f �r • TI/E; II I. A el TION OF A OF'TINE ADOVE TAT EI.IENIa MAY SUBJECT SHE [NNI;RAC70R In addition to the basic hourly wage rates paid to each laborer or mechanic . 000 '8UGCOHIRACIOR'10 CIVIL OR CRIMINAL PRO UllON. SEE SECTION 1001 OF TULE IS AND listed In the above referenced payroll, payments of fringe benefits as listed in the SECTION 271 OF TITLE 31 OF THE UNITED RTATES CODE, • • Hage:4iin Construction Corp Certified Payroll Report 06-24-2010 Page 4 For the Period Ending: 06-20-10 Job:08-2613- Carmel Reg Performing Arts Cen 211 CITY CENTER DRIVE CARMEL, IN 46032 '.; \i.6 JOHN C SCHULTZ RR 2 BOX 630 COAL CITY, IN 47427 06-14 06-15 06-16 06-17 06-18 06-19 06-20 Total Cash Hrly Gross Total FWH SWH Other 309-50-8873 Caucasian Male Mon Tue Wed Thu Fri Sat Sun Hours Rate Fringe Fringe This Job Gross FICA SUI/SDI Deducts Net M - 1 Carpenter Reg 8.00 8.00 34.33 274.64 1,373.20 145.45 46.03 126.84 949.83 274.64 105.05 J D WILLIS 5604 BERTHA ST INDIANAPOLIS, IN 46241 06-14 06-15 06-16 06-17 06-18 06-19 06-20 Total Cash Hrly Gross Total FWH SWH Other 307-66-1396 Caucasian Male Mon Tue Wed Thu Fri Sat Sun Hours Rate Fringe Fringe This Job Gross FICA SUI/SDI Deducts Net M - 0 Laborer Reg 8.00 8.00 23.63 189.04 945.20 91.78 32.14 53.41 695.56 189.04 72.31 MICK L LEAS 8924 S MAIN ST PETROLEUM, IN 46778 06-14 06-15 06-16 06-17 06-18 06-19 06-20 Total Cash Hrly Gross Total FWH SWH Other 304-04-2317 Caucasian Male Mon Tue Wed Thu Fri Sat Sun Hours Rate Fringe Fringe This Job Gross FICA SUI/SDI Deducts Net S - 0 Cement Mason Reg 8.00 8.00 8.00 24.00 31.95 766.80 1,022.40 164.61 34.76 161.10 583.71 766.80 78.22 DAVID D CULPEPPER 910 CLOVERLEAF TERRACE INDIANAPOLIS, IN 46241 06-14 06-15 06-16 06-17 06-18 06-19 06-20 Total Cash Hrly Gross Total FWH SWH Other 312-78-2232 Black Male Mon Tue Wed Thu Fri Sat Sun Hours Rate Fringe Fringe This Job Gross FICA SUI/SDI Deducts Net S - 1 Cement Mason Reg 8.00 8.00 29.29 234.32 234.32 4.78 7.31 40.67 163.64 234.32 17.92 Totals for Carmel Reg Performing Arts Cen 06-14-10 06-15-10 06-16-10 06-17-10 06-18-10 06-19-10 06-20-10 Total Gross Total Monday Tuesday Wednesdy Thursday Friday Saturday Sunday Hours This Job Gross Deductions Net 32.00 8.00 .00 .00 8.00 .00 .00 48.00 1,464.80 3,575.12 FWH 406.62 2,392.74 FICA 273.50 SWH 120.24 SDI .00 Other 382.02 08-2613-A Hagerman Construction Corp. P 0 Box 10690 Fort Wayne, IN 46853-0690 STATEMENT OF COMPLIANCE Week Ending: 06-20-2010 (Certification Report Form WH-347) Carmel Reg Performing Arts Cen I, Richard E. Sutorius (Name of signatory party) , Secretary (Title) do hereby certify under penalty of perjury: (1) That I pay or supervise the payment of the persons employed by Hagerman Construction Corp. on the Carmel Reg Performing Arts Cen; that during the payroll period commencing on the 14 day of June 2010, and ending the 20 day of June 2010, all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Hagerman Construction Corp. from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357; 40 U.S.C. 276c) , and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: a WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the bove referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS: ,) Secretary j {�� gr �v Ric and E. Sutorius THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED STATES CODE. I .c, PAYROLL CER'llitICATION PROJECT NO. HCC Job #2613 ' #2695 I CERTIFY THAT THE PAYROLL RECORDS FOR flaiarman Construction Corporation (Contractor) PAY PERIOD FROM bk1/(0 TO -7/A6o ARE:TRUE A_ND CORRECT, TO THE BEST OF MY KNOWLEDGE AND BELIEF AND THE WAGE SCALE AS REQUIRED BY I.C. 5-16-7-1 HAS BEEN ADHERED TO. STATE OF •Tneli-ana ) ) SS: COUNTY OF . Allen ) BEFORE ME, THE UNDERSIGNED, A NOTARY PUBLIC, PERSONALLY APPEAIRE15 e4Ai2,1--7c--,- 04.4.1.AS ; WHO (Name) (Title) ACKNOWLEDGED EXECUTION OF THE ABOVE CERTIFICATION THIS )0--DAY OF 10. Alp* . teilk -i" 4.1PCIf4/44412 ' 4$0, NOTARY PUBLIC (Signature) • 04,141.2, uiv5. • NOTARYSEAL Z_At '7-;)".:62:11;e:Ncou0.4:7 David C. Thomas NAME (Printed) MY COMMISSION EXPIRES: • _RESIDING IN Allen COUNTY 12/16/15_ REV 2/98 SOBC-7 Monthly Employment Utiilzation Report -U.S. Department of Labor - Employment Standards Administration `' ' Office of Federal Contract Compliance Programs - This report Is required by Executive Order 11246,Sec.203.Failure to report can result In contracts 1. Covered Area(SMSA or EA) 2. Employers I.D. No. OMB No. 1215-0163 being cancelled,terminated or suspended In whole or In part and the contractor may be declared Expires: 12/31/92 Ineligible for further Government contracts of federally assisted construction contractor Hami 1 ton • 35-OR1 34 0 3. Current Goals 4. Reporting Period Name and Location of Contractor Federal Hagerman Construction Corporation Funding Minority Fromh23i 1 ID P.O. BOX 10690 Agency Female To -7 'Ji0 Fort Wayne, IN 46853 • .: 6, , 8. TOTAL FEDERAL& NON-FEDERAL CONSTRUCTION WORK HOURS 9. 10. 6a. 6b. . 6c. 6d. 6e. 7. 8. CONSTRUCTION Total All Black Asian or American Total Total Number TRADE_• : • Classifications Employees (Not:of Hispanic Pacific Indian or Number of of.Minority By Trade Origin).` Hispanic Islander Alaskan Native Minority Female Employees Employees M F . M. F N : F M F M F Percentage Percentage M F M Journey Worker Apprentice ._;�_. . _ -- -- _-- _ ___- ----- Trainee ;;;::•:;;:r:::•:�::;:::;;:�:c:c;;:•::.:�::::•:::::•.- •::::::::.:�::::::.�::•:::•::•::::::::::::::::::.-::::::::::::;;•:�;�•>::�::;•;•;�>:a;:;:•>;:a:;•:a;:;:tt•;>;::•s>;:;:cz.:;::::.-:•::::::::.:�:::::.-::::.:�:::::::::::::.�•::::::: :::.�:::::::::::.�:,.::::::::::::::::::•:•:::.:..:::•::::::::::•:•:::::::::::�:.;:�::;::::..... ... ....,.........:::••::: •:::::::::.:.• • Sub-Total ................................�.� •, Journey Worker _ Apprentice i Trainee T ta` • Journey Worker .- Apprentice SEE ATTACHED • Trainee . Sub-Total ........................................................................ .............. .................................................................................. ..... •. Journey Worker - • • Apprentice • Trainee Sub-Total Journey Worker Apprentice • Trainee . Sub-Total . .. ....... ..... ... .. ......... ......._. .._....... ... ............... .... .... - Total Journey Workers Total Apprentices Total Trainees s • i Grand T e ta I ............................................. .......................... :i............ .,.................................,.•.. ..............:.t.t ss > 11. Comp/y.Dff tars ig an Title _ s1:0_,-----� 12 Telephone Nu mber ......................-..........3..... Date Signed..............................:.:.................P... ....9 (Include area code) .:.- .................,................._-. of n I etIAT-D .S Le vU t�5 i f411- (260) 424-1470 w Fnrin rr-9F7/yn ` a Monthly Employment Utilization Report Page 7 , U.S. Department of Labor, Form CC-257 System Date: 07-29-2010 • • ' Reporting Period: 06-21-10 to 07-25-10 � Job# 082613A - Carmel Reg Performing Arts Cen County: CO Total All Employees Asian/ American Indian/ Total Minority \Construction By Trade Black Hispanic Pacific Islander Alaskan Native Minority Female Employees Employees Trade Class Male Female Male Female Male Female Male Female Male Female % % M F M F Laborer Journeyman 2.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 1 0 0 0 Sub-total 2.00 .00 .00 .00 .00 .0 .0 Job Totals 2.00 .00 .00 .00 .00 .00 .00 .00 .00 .00 1 0 0 0 • h • J , U.S. DEPARTMENT OF LABOR rs .- PAYROLL Fo,m *pprovd. WALE AND 11005 DIVISION Sadie, Donau No. 44-n1093 • • (For Contractor's Optional Use;See Instruction, Form WH-347 Inst.) NAME OF COITTRACTOn 0 On SUBCONTRACTOR I ADDRESS Hagerman Construction Corporation P.O. Box 10690, Fort Wayne, TN 46i PAYROLL N0. I FOR WEEK ENDING q PROJECT AND LOCATION PROJECT OR CONTRACT NO. UI rn an. 1• (41 AY AND DATE (r (IR• m (5) CC Job u X695�1 • >i v, DEDUCTIONS NAME,ADDRESS AND 9 WORK p—--�—I—I—I_ TOUR! RATAY' AMOUNT wlnl• . Tarsi P^ES • SOCIAL SECURITY NUMBER `o g CLASSIFICATION 1 OF EMPLOYEE f EARNED FICA NOLDINO OTIIER DEDUCTION(lig • O. 110(1119 WORKED EACII DAY TAX FOR WEEK 0 - 0 . S 0 ' s . • E ATTACHED D s • . O • s. D • . , s - . . . D S .. - D . • • s O - s roRU WII-9l7 NJEe1- ronMEnLY sot. um—PURCHASE THIS FORM DIRECTLY FROM THE SUPT. OF DOCUMENTS S ( 'D"to / 7 cP-59)D contract have been or will be made to appropriate programs for the benefit of such j'( _ employees,except as noted In Section 4(c)below. I' (Na s or signatory p sly)I ,Ej'� `�'°le) (b) WHERE FRINGE BENEFITS ARE PAID IN CASH do hereby state: [3 —Each laborer or mechanic listed In the above referenced payroll has been paid, as • indicated on the payroll, en amount not less than the sum of the applicable bask (1)That'I pay or supervise(lie payment of the persons employed by Hagerman hourly wage rata plus the amount of the required fungi benefits us listed In the , contract,except as noted In Section 4(c)below. Construction Corp. an the Carmel PP forming Arts ' • (Contractor or subcontractor) ' (Building or erorp S� `;'-(c) EXCEPTIONS Center •that du ing the payroll period comma clog on the ) ' • - �� f rJ EXCEPTION (CRAFT) EXPLANATION day of end ending th / y . all persons employed on said project hove been paid the full weekly.wages earned,that no rebates • . have been or will be made either directly or Indirectly to or on behalf of said • Hagerman Construction Corporation from the full ' _ (Contractor or subcontractor) .- weekly wages earned by any person end that no deductions have been made either directly or . Indirectly from the lull wages earned by any person, other than permissible deductions as defined In Regulations, Part 3 (29 CFR Subtitle A), Issued by.the Secretary of Labor under the Copeland Act,as amended (48 Stat.948,63 Stat. 108,72 Stat.967;76 Stat.357;40 U.S.C.276c),end de- scribed below: ' • • • SPASMS - ' . • (2) That any payrolls otherwise under this contract required to be submitted for the above - • . period are correct and-complete;.that the wage rates for laborers or mechanics contained therein are nut less than the applicable wage rates contained In any wage determination Incorporated Into - the contract;that the classifications set forth therein for each laborer or mechanic conform with the • - . • work he performed. • (3) That any apprentices employed In the above period era duly registered In a bong lido apprenticeship program registered with a Stale epprenticeshlp agency recognized by the Bureau , of Apprenticeship and Training,United Stales Departntent of Labor,or II no such recognized agency exists In a Siete,are registered with tire Bureau of Apprenticeship and Training,United States Depart- ment of Labor. (4) That; AND TITLE ' SIONATU• I�_' / 1• ; ._ qAc C I(u) WH ERE FRINGE DENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS rrrA �.sue,.(2l ;t i _ _ /•"�� r !'��lll..JJJ,a.k`(000 � a TIIE;WIt FM ►ALnIFICAT10N OF A OF Tr1E AOOV 'TATEMENTs MAY SUBJECT THE CONTRACTOR ),N —In addition to the basic hourly wage rates paid to cacti laborer or mechanic "On `BUBCONERACtOR'70 CIVIL OR CRIMINAL PRO ECONON. SEE SECTION 1001 OF TITLE Is AND LYt! listed In the above referenced payroll, payments of fringe benefits es listed In the SOON 231 OF TITLE 31 OF THE UNITED.arATES GOOF Hagerr,;n Construction Corp Certified Payroll Report 07-01-2010 Page 4 For the Period Ending: 06-27-10 Job:08-2613- Carmel Reg Performing Arts Cen s 211 CITY CENTER DRIVE CARMEL, IN 46032 el J D WILLIS 5604 BERTHA ST INDIANAPOLIS, IN 46241 06-21 06-22 06-23 06-24 06-25 06-26 06-27 Total Cash Hrly Gross Total FWH SWH Other 307-66-1396 Caucasian Male Mon Tue Wed Thu Fri Sat Sun Hours Rate Fringe Fringe This Job Gross FICA SUI/SDI Deducts Net M - 0 Laborer Reg 2.00 2.00 23.63 47.26 945.20 91.78 32.14 53.41 695.56 47.26 72.31 Totals for Carmel Reg Performing Arts Cen 06-21-10 06-22-10 06-23-10 06-24-10 06-25-10 06-26-10 06-27-10 Total Gross Total Monday Tuesday Wednesdy Thursday Friday Saturday Sunday Hours This Job Gross Deductions Net 2.00 .00 .00 .00 .00 .00 .00 2.00 47.26 945.20 FWH 91.78 695.56 FICA 72.31 SWH 32.14 SDI .00 Other 53.41 -:A 08-2613-A Hagerman Construction Corp. P 0 Box 10690 Fort Wayne, IN 46853-0690 STATEMENT OF COMPLIANCE Week Ending: 06-27-2010 (Certification Report Form WH-347) Carmel Reg Performing Arts Cen I, Richard E Sutorius (Name of signatory party) , Secretary (Title) do hereby certify under penalty of perjury: (1) That I pay or supervise the payment of the persons employed by Hagerman Construction Corp. on the Carmel Reg Performing Arts Cen; that during the payroll period commencing on the 21 day of June 2010, and ending the 27 day of June 2010, all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said Hagerman Construction Corp. from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967, 76 Stat. 357; 40 U.S.C. 276c) , and described below: (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: ( ) HERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the ab e referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4(c) below. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION REMARKS: Alf It // I Secretary ry L.I���. fir r 1 R 7hard E Sutorius THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31 OF THE UNITED STATES CODE. 1