HomeMy WebLinkAbout223996 09/10/2013 »,F CITY OF CARMEL, INDIANA VENDOR: 367514 Page 1 of 1
ONE CIVIC SQUARE JBM CONTRACTORS CORP CHECK AMOUNT: $24,953.00
�ta CARMEL, INDIANA 46032 5299 W OLD 106TH ST
• ,,a� ZIONSVILLE IN 46077 CHECK NUMBER: 223996
CHECK DATE: 9/10/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 24, 953 . 00 OTHER EXPENSES
APPLICATION AND CERTIFICATION FOR PAYMENT PAGE ONE OF 1 PAGES 2
TO OWNER: PROJECT: Proposed Renovations APPLICATION NO: 1 Distribution to:
City of Carmel,Indiana-Board of Public Works and Safety Second Floor Unit Located 30 W.Main St. OWNER
One Civic Square Contract No.91 xxx I ARCHITECT
Carmel,IN 46032 PERIOD TO: 8/19/2013-8/30/2013 CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT: MAWR Design,Inc.
JBM Contractors Corp 849 South Park Drive _
5299 W Old 106th Street Carmel,Indiana PROJECT NOS: JBM 13-18
Zionsville,Indiana 46077
CONTRACT DATE:
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge,
Application Is made for Payment,as shown below,in connection with the Contract. information and belief the Work covered by this Application for Payment has been
Continuation Sheet,AIA Document G703,is attached. completed in accordance with the Contract Documents,that all amounts have been paid by
the Contractor for Work which previous Certifications for Payment were issued and
payments received from the Owner,and that current payment shown herein is now due.
1 ORIGINAL CONTRACT SUM $ 164,918
2 Net change by Change Orders $ 0 CONTRACTOR-
3 CONTRACT SUM TO DATE(Line 1+2) $ 164,918 CONTRACT
4 TOTAL COMPLETED&STORED TO $ 26,266
DATE (Column G on G703) By: Data:`^ a a
5 RETAINAGE:
a. 0 %of Completed Work State of: CO MUM JOHN STUERENEERG
(Column D+E on G703) $ 1,313 Subscribed and sworn to bef this day of SEAL
b. %of Stored Material Notary Public:
(ColumnFonG703) $ My Commission expires: Notary PUbIICr State of Indiana
(Column
Retains G(Line Sa+Sb or TiZ�2�� Feb.22,2020
Total Total in Column I of G703) $ 1,313 ARCHITECT'S CERTIFICATE FOR P
6 TOTAL EARNED LESS RETAINAGE $ 24,953 In accordance with the Contract Documents,based an on-site observations and the data
(Line 4 less Line 5 Total) comprising this application,the Architect certifies to the Owner that to the best of the
7 LESS PREVIOUS CERTIFICATES FOR Architect's knowledge,information and beliefthe work has progressed as indicated,
PAYMENT(Line 6 from prior Certificate) $ 0 the Quality of the Workis in accordancewith the Contract Documents,and the Contractor
8 CURRENT PAYMENT DUE $ 24,953 isent itedto payment ofthe AMOUNT CERTIFIED.
9 BALANCETO FINISH,INCLUDING RETAINAGE $ 1391965
AMOUNT CERTIFIED.............................._...$ 24,953
(Line 3 less Line 6)
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation ifamountcertifieddiffersfrom the amount applied.initial ailfiguresonthis
Total changes approved in Application and on the Continuation Sheet that are changed to conform with the amount certified.)
previous months by Owner 0 ARCHITECT:
Total aproved this Month
0 O By: Date:
This Certificate Is not negotiable.The AMOUNT CERTIFIED is payable only to the
TOTALS 01 0 Contractor named herein.Issuance,payment and acceptance of payment are without
prejudice to any rights of the Owner or Contractor under this Contract.
NET CHANGES by Change Order 0
Prescribed by State Board of Accounts
Form No.301-S(Rev.1997) ACCOUNTS PAYABLE VOUCHER
TO
ADDRESS
Invoice Date Invoice Number Item Amount
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and that the materials or services
itemized thereon for which charge is made were ordered and received except
Mo. Day Yr. Signature Title
I hereby certify that the attached invoice(s), or bill(s), is (are)true and correct and I have audited same in accordance
with IC 5-11-10-1.6.
Mo. Day Yr. icer Title
Voucher No Warrant No.
ACCOUNTS PAYABLE DETAILED ACCOUNTS
MUNICIPAL WASTEWATER UTILITY ACCT.
675 CARMEL, INDIANA
5 Favor Co 110
5z�q w o/d 1 o6 t h s t
2rbti5V,'(1e 1W '-160
Total Amount of Voucher
Deductions
Amount of Warrant U
Month of Yr
VOUCHER RECORD Acct.No.
Collection System
Pumping
Treatment&Disposal
Customer Accounts
Administrative&General
Reclaimed Water Treatment
r'?claimed Water Distribution
Total
Allowed
Board Members
Filed
BOYCE FORMS•SYSTEMS 1-800-382-8702 325