HomeMy WebLinkAboutSIGNATURE CONSTRUCTION SERVICES LLC- 817.55- 2/22/2011 - NO CHECK WRITTEN BY CRC b
APPLICATION AND CERTIFICATION FOR PAYMENT AM DOCUMENT G702 PAGE ONE OF 2 PAGES 2
TO OWNER Carmel Theater Development Conte PROJECT: Carmel City PIII Waterproofing APPLICATION NO Invoice It 15 I Distribution to:
Invoice# IS Signature costs OWNER
Carmel Indiana 46032 ]ARCHITECT
PERIOD TO: 02/22/2011 X CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT: I'edcor Design
Signature ConstructionServicesd.L-EC- 1
720 3rd Avenue S.W. PROJECT NOS:
Carmel, Indiana 46032
CONTRACT FOR: CONTRACT DATE:
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of Contractors knowledge,
Application is made Mr payment,as shown below,in connection with the Contract. information and belief the Work covered by this Application for Payment has been
Continuation Sheet,AIA Document G703,is attached. completed in accordance with the Contract Documents,that all amounts have been paid by
the Contractor for Work for which previous Certificates for Payment were issued and
payments received front the Owner,and that current payment shown herein is now due.
I. ORIGINAL CONTRACT SUM 175,137.69
2. Net change by Change Orders 0.00 CONTRACTOR:
3. CON'I'RAC I'SUM TO DATE(Line 1 t 2) $ 175,137.69
4. TOTAL COMPLETED&STORED TO $ 167,625.86
By: 7 Date: L/I L //
5. RETAINAGE: /Thomas V-'oontz,President ,rah, 7/
a. 0 %of Completed Work $ 0 Suhs:rihed am worn to before me this 0.2 day of Dceember 2009
(Column D+E on G703)
b. %of Stored Material $ '1,0.::t.,...., LINDA BUCHANAN
=.a. _ Hancock County
(Column P on G703) My Commission Expires
Total Retainage(Lines 5a+5b or `+l '" 5-; -...-,;` n.,„oc,on 2011
Total in Column l of G703) $ 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT -
6. I 01 AL EARNED LESS RETAINAGE S 167,625.86 In accordance with the Contract Documents,based on on-site observations and the data
(Line 4 Less Line 5 Total) comprising the application,the Architect cenifies to the Owner that to the best of the
7. LESS PREVIOUS CER'T'IFICATES FOR Architect's knowledge,information and belief the Work has progressed as indicated,
PAYMENT(Line 6 from prior Certificate) $ 166,808_31 the quality of the Work is in accordance with the Contract Documents,and the Contractor
8. CURRENT”PAYMENT DUE $ 817.55 is entitled to payment of the AMOUNT CERTIFIED.
9- BALANCE TO FINISH,INCLUDING RETAINAGE $ 7,511.83 _
(Line 3 less Line 6) A:MOUNI'CERTIFIED $ X17.JS
•
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation if amount certified l9ersfrom the amount applied. Initial all figures on this
Total chances approved Application and anthe dial ,et that are h aged to conform with the amount certified.)
in previous months by Owner ARCHITECT: v /1 (t
Total approved this Month Br. -s ''1a �` �� : ,,L.,.Jf/`L71 l`
TOTALS $0.00 $0.00 This Cc ificate is not re unable. The AMO NT CERTIFIED is payable only to the/
Contract( named he 1R issuance,paymen ana acceptance 01 payment are witnout
NET CHANGES by Change Order $0.00 prejudice t. 'ny ri_' s of the Owner or Contractor under this Contract.
AIA DOCUMENT G702•APPLICATION AND CERTIFICATION FOR PAYMENT•1992 EDITION-AIA -01992 THE AMERICAN INSTITUTE OF ARCHITECTS,1735 NEW YORK AVE.,NW,WASHINGTON,DC 2000-5292
Users may obtain validation of this document by requesting a completed AIA Document 0401 -Certification of Document's Authenticity from the Licensee.
Director of Redevelopment 4' b 03 67
SIGNATURE CONSTRUCTION LLC
720 3rd Avenue, S. W.
Carmel, Indiana 46032
I I I I I
Invoice # 15
2/22/11
Carmel City P111 Waterproofing - Gibraltar
Carmel ,_ Indiana
Total Work RETAINAGE 1 BALANCE
Scheduled Completed WITHHELD PREVIOUS TOTAL COMPLETED TO
DESCRIPTION Value This period THIS PERIOD APPLICATIONS TO DATE 1 % FINISH
Pre-Construction Services:
Project Management 0.00 0.00 0.00 3,117.15 0.00 100E 0.00
Site Supervision 0.00 0.00 0.00 4,173.64 0.00 100% 0.00
General Conditions: GIBRALTAR
Testing and Inspecting 2,500.00 0.00 0.00 1,796.21 1,796.21 72% 703.79 •
Project Management 1,500.00 0.00 0.00 758.46 758.46 51% 741.54
Site Supervision 68,353.00 0.00 0.00 68,033.33 68,033.33 100% 319.67
Site Safety Director 3,811.31 0.00 0.00 3,811.31 3,811.31 100% 0.00
Design Drawings 4,184.47 0.00 0.00 4,184.47 4,184.47 100E 0.00
Temporary Electric 0.00 0.00 0.00 0.00 0.00 0% 0.00
Office Supplies 1,000.00 0.00 0.00 770.97 770.97 77% 229.03
Tools and Equipment 1,618.12 0.00 0.00 1,618.12 1,618.12 100% 0.00
Field Engineering and Surveying 4,601.79 0.00 0.00 4,601.79 4,601.79 100% 0.00
Construction Management Fee 87,569.00 817.55 0.00 81,233.65 82,051.20 94% 5,517.80
175,137.69 817.55 0.00 166,808.31 167,625.86 96% 7,511.83
•
CONDITIONAL AFFIDAVIT AND WAIVER OF LIEN
STATE OF INDIANA
COUNTY OF HAMILTON )
Thomas E. Koontz being duly sworn states that he is the President of Signature
Construction, LLC having contract to furnish certain materials and/or labor as
follows: Construction Management Services for a project known as Carmel City
Center P111, located at Carmel, Indiana and owned by the
Carmel Theatre Development Company and does state:
CONDITIONAL WAIVER:
that the balance due from the owner is the sum of eight hundred
seventeen dollars and fifty-five cents ($817.55) the payment of which has been
promised as the sole consideration for this Affidavit and Conditional Waiver
of Lien which is given to and for said amount, effective upon receipt of such
cash payment.
THEREFORE, the undersigned waives and releases unto the Owner of said premises any
and all line or claim whatsoever on the above-described property and improvements
thereon on account of labor or material or both, finished by the undersigned thereto, and
further certifies that no other party has any claim or right to a lien on account of any
work perform or material furnished to the undersigned for the said project, and within the
scope of this affidavit and waiver.
SIGNATURE CONSTRUCTION, LLC
Tho as E. ontz, President
Subscribed and sworn to before me this: ,fir A. 07J >o i/
Notary Public:
v. . LINDA BUCHANAN
e . "
,f,+•��� x Hancock County
My Commission Expires
August 20,2011