Broady-Campbell, Inc Application and Certificate for Payment
TO OWNER: CARMEL THEATER DEVELOPMPROJECT: VILLAGE ON THE GREEN 7-C APPLICATION NO: 4 Distribution to:
• OUST# CAR4 11711 N. PENN ST. PERIOD TO: 01/31/2011 OWNER
SUITE 200
CARMEL IN 46032 CONTRACT FOR: 12012
ARCHITECT
FROM CONTRACTOR: BROADY-CAMPBELL INC. VIA ARCHITECT: CONTRACT DATE: 06/23/2010 CONTRACTOR
2115 Dr.A.J.Brown Ave. PEDCOR DESIGN GROUP
PROJECT NOS: FIELD
Indianapolis,IN 46202
VILLAGE ON THE GREEN 7-C JOB N 210056 OTHER
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge. inforn,ntmon
Application is made for payment, as shown below, in connection with the Contract and 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 lot
Continuation Sheet, is attached. previous Certificates for Payment were issued and payments received from the Owner, and
1. ORIGINAL CONTRACT SUM $ that current payment shown herein is now due.
2. Net change by Change Orders
-19,805 00
9 Y 9 $ CONTRACTOR: Broady—Cam bell, Inc.
878,195.00
3. CONTRACT SUM TO DATE (Line 1 +2) $ By: . D,11e: 1-31-2011
4.TOTAL COMPLETED& STORED TO DATE (Column G on 603LS1).... $ 442,935.50 State of Indiana
5. RETAINAGE: County of Marion
a. 10.00%of Completed Work
P Subscribed and sworn to before
(Column D+ Eon 603LSI) $ 44,293.55 me this
b. 10.00%of Stored Material 31st day of January 2011
(Column F on 603LS1) $ 0.00 Notary Public: cL1Q
Total Retainage(Lines 5a+ sb or Total in Column 1 of 603LS 1) ... $
44,293.55 My Commission expires: 5-5-2016
6.TOTAL EARNED LESS RETAINAGE $ 398,641.95 ARCHITECT'S CERTIFICATE FOR PAYMENT
(Line 4 Less Line 5 Total) In accordance with the Contact Documents, based on on-site observations and the data comprising
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT 277,857.09 this application, the Architect certifies to the Owner that to the best of the Architect's knowledge
$ information and belief the Work has progressed as indicated, the quality of the Work is in
(Line 6 from prior Certificate) accordance with the Contract Documents, and the Contractor is entitled to pad inent of the
8. CURRENT PAYMENT DUE $ 120,784.86 AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE AMOUNT CERTIFIED 42.0 781, -eta
( 6) 479,553.05 4ltoch ev tlanuliort if amount coin Wier(di er tom the amore/a/>ltiied. 11111 of(11, 11:;fouc'.c uu this
Line 3 less Line 6 $ ( 1 / i � %/'�,�/
_ Applicalion and on in tin notion Sheet that cnc can$,;tc/ o coal() n 1 nth thr«mount ccr till(0;.
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS ARCHITECT: --',/
p—e."
0.00 19,805.00 1,
Total changes approved in previous months by Owner $ $
1
0.00 0.00 By ' — -- Bate:.� t
Total approved this Month $ $ !!
TOTALS $ 0.00 $ 19,805.00 This Certit not negotiable The AMOUNT CERTIFII I) is payable only t the Contractor
19
named named herein. ssuancc, payment and acceptance of payment arc witi out prejudice to any rights of
NET CHANGES by Change Order $ the Owner or Contractor under this Contract.
REORDER FORM NO.G04LS1 '{�
►Yr
Continuation Sheet ADA Document G703-1992 (Instructions on reverse side.) Page 1 of 2
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.: 4
containing Contractor's signed Certification, is attached.
In tabulations below, amounts are stated to the nearest dollar. APPLICATION DATE: 01/31/2011
Use Column 1 on Contracts where variable retainage for line items may apply. PERIOD TO: 01/31/2011
ARCHITECT'S PROJECT NO: 12012
A B C D E F G H I
WORK COMPLETED
MATERIALS TOTAL
ITEM SCHEDULED PRESENTLY COMPLETED aka TO BALANCE RETAINAGE
FROM PREVIOUS
DESCRIPTION OF WORK VALUE STORED AND STORED
.
APPLICATION THIS PERIOD (G _ C) FINISH CIF VARIABLE)
NO
(D + E) (NOT IN TO DATE (C G) RATE)
-
D OR E) (D+E+F)
01 104-4100 GENERAL 26,000.00 6,500.00 3,900.00 10,400.00 40.00 15,600.00 1,040.00
CONDITIONS
02 104-4101 BOND 8,000.00 8,000.00 8,000.00 100.00 800.00
03 104-4102 BLOCK LABOR 9,400.00 4,230.00 940.00 5,170.00 55.00 4,230.00 517.00
04 104-4103 BLOCK 2,700.00 1 ,485.00 270.00 1,755.00 65.00 945.00 175.50
MATERIAL
05 104-4104 EAST FACE 121,430.00 25,500.30 27,928.90 53,429.20 44.00 68,000.80 5,342.92
BRICK LABOR
06 104-4105 EAST BRICK 56,400.00 24,252.00 14,100.00 38,352.00 68.00 18,048.00 3,835.20
MATERIAL
07 104-4106 SOUTH FACE 104,560.00 15,684.00 15,684.00 15.00 88,876.00 1,568.40
BRICK
08 104-4107 SOUTH BRICK 48,600.00 5,346.00 13,608.00 18,954.00 39.00 29,646.00 1,895.40
MATERIAL
09 104-4108 WEST FACE 1 15,100.00 1 15,100.00
BRICK LABOR
10 104-4109 WEST BRICK 53,500.00 5,885.00 3,745.00 9,630.00 18.00 43,870.00 963.00
MATERIAL
11 104-4110 WEST 6,500.00 6,500.00
LIMESTONE LABOR
12 104-4111 WEST 24,500.00 22,050.00 2,450.00 24,500.00 100.00 2,450.00
LIMESTONE MATERIAL
13 104-4112 WEST 14,800.00 14,800.00
PAGE TOTALS : 591,490.00 103,248.30) 82,625:90 .00 185.874.20 405..615 80 I R5R7 47
G703-1992
Continuation Sheet AIA ,wocument G703-1992 (Instructions on reverse side.) Page 2 of 2
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.:
containing Contractor's signed Certification, is attached. 4
In tabulations below, amounts are stated to the nearest dollar. APPLICATION DATE: 01(31(2011
Use Column I on Contracts where variable retainage for line items may apply. PERIOD TO: 01/31/2011
ARCHITECT'S PROJECT NO: 12012
A B C D E F G H I
WORK COMPLETED
MATERIALS TOTAL
ITEM DESCRIPTION OF WORK SCHEDULED PRESENTLY COMPLETED oho BALANCE RETAINAGE
NO. VALUE FROM PREVIOUS STORED AND STORED (G _ C) TO CIF VARIABLE)
APPLICATION THIS PERIOD (NOT IN TO DATE FINISH RATE)
(D + E) D OR E) (D+E+F) (C-G)
'I, 4ITE LABOR
14 104-4113 WEST 60,720.00 60,720.00
60,720.00 100.00 6,072.00
GRANITE MATERIAL
15 104-4114 NORTH FACE 80,550.00 20,943.00 47,524.50
68,467.50 85.00 12,082.50 6,846.75
BRICK LABOR
16 104-4115 NORTH BRICK 37,500.00 35,625.00 1,875.00 37,500.00 100.00
MATERIAL 3,750.00
17 104-4116 NORTH 10,900.00 7,303.00 2,180.00
9,483.00 87.00 1,417.00 948.30
LIMESTONE LABOR
18 104-4117 NORTH 41,500.00 41 ,500.00 41,500.00 100 4,150.00
LIMESTONE MATERIAL
19 104-4118 NORTH 9,860.00 8,676.80 8,676.80 88.00 1,183.20 867.68
GRANITE LABOR
20 104-4119 NORTH 40,480.00 40,480.00 40,480.00 100
GRANITE MATERIAL 4,048.00
21 104-4120 ALLOWANCE 25,000.00 10,039.00
22 104-4121 CO#52 TAX -19,805.00 -19,805.00 19,809.00 00.10 14,961.00 1,003.90
EXEMPTION
19,805.00 100.00 -1,980.50
JOB TOTALS :
878,195.00 308,730. 10 ) 134,205.40 .00 442,935.50 50% 435,259.50 44,293.55
I _
G703-1992