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HomeMy WebLinkAbout2012 CRC Nash Building pay request 01 L,,IOPMINt, ; 1 � CRC i CARMEL REDEVELOPMENT COMMISSION Disbursement Number#1 E-Mail the signed Disbursement Direction to: James Brainard Mayor Huntington National bank Corporate Trust Department(INHP22) Commissioner: Attn: Kim Wilson kim.wilson @huntington.com (317)229-4094 William Hammer Ellen Campbell Ellen.campbell@huntington.com (616)235-5941 President David Bowers Vice President Re: Depository Agreement between the City of Carmel and Huntington National Bradley Meyer Bank, dated December 31,2012-Trust#4087000414 Secretary Tom Crowley Commissioner Dear Kim: Jeff Worrell On October 3, 2013,you are hereby authorized and directed,as the Depositary Commissioner under the above referenced Agreement,to pay the amounts set forth on the attached Register of Claims from the above-referenced Trust account and overnight Gregory Phillips checks to: Commissioner Carmel Redevelopment Commission Attention: Matt Worthley Les Olds,AIA 760 Third Avenue SW—Suite 110 Executive Director Carmel,IN 46032 City of Carmel, IN Diana L.Cordray, Clerk-Treasurer 30 WEST MAIN STREET, SUITE 220, CARMEL, IN .46032 OFFICE 317.571.ARTS (2787) FAX 317.571.2789 CARMEL REDEVELOPMENT COMMISSION Register of Claims 10/3/2013 Payment Request #1 Amount of Wire Vendor (Address Invoice Description Instructions 720 3rd Ave SW Carmel,IN pay app 1,Nash garage Signature Construction Services 46032 $ 71,859.76 construction mgt IF NEEDED 2932 N Webster Ave Gibraltar Construction Corp • Indianapolis,IN 46219 $ 309,510.00 Pay app 1,Garage&ramp IF NEEDED 2747 N Emerson Ave Robert Haines Company Indianapolis,IN 46218 $ 25,583.00 Pay app 1,Garage&ramp IF NEEDED Total: $ 406,952.76 ALLOWANCE OF CLAIMS We have examined the claims listed on the above Register of Claims,consisting of 1 page(s),and except for claims not allowed as shown on the register such claims are hereby allowed in the total amount of: $ 406,952.76 e 3 Director of the CRC Da e '.4 APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE ONE OF 2 PAGES 2 TO OWNER CRC at City of Carmel PROJECT: Nash Garage APPLICATION NO:Application a 1 Distribution to: Carmel Indiana 46032 Signature costs OWNER ARCHITECT PERIOD TO: 9/25/2013 X CONTRACTOR FROM CONTRACTOR: VIA ARCHITECT:Pedcor Design I Signature Construction Services LLC 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 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 for which previous Certificates for Payment were issued and payments received from the Owner,and that current payment shown herein is now due. I. ORIGINAL CONTRACT SUM $ 156,776.00 2. Net change by Change Orders $ 0.00 CONTRACTOR: 3 CONTRACT SUM TO DATE(Line I+2) $ 156,776.00 4 TOTAL COMPLETED R STORED TO $ 71,859.76 By: !r I Date: / G /, 5. RETAINAGE: p s p� 5 eLrht , y 4efi&LQe,2 t 2013 a_ 10 %of Completed Work $ 0 p scribed n. e o t (Column D f E on Mate b. %ofStored Material $ Notary Public Sea! 1 i l� PLO"' (Column F on G703) Slate of Indiana cec�����1 Total Retainage(Lines 5a+5b or 4 My Commission Expires Aug 18, 2018 Total in Column lofG703) $ 0.00 A" •. '' ,' s- '7' 'I,-'wv'-,-.. —47 PAYMENT 6. TOTAL EARNED LESS RETAINAGE $ 71,859.76 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 certifies to the Owner that to the best of the 7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge,information and belief the Work has progressed as indicated, PAYMENT(Line 6 from prior Certificate) $ 0.00 the quality of the Work is in accordance with the Contract Documents,and the Contractor 8. CURRENT PAYMENT DUE $ 71,859.76 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH,INCLUDING RETAINAGE $ 84,916.24 9 1` (Line 3 less Line 6) AMOUNT CERTIFIED $ 71 . ,7to CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation ifamous!certified differs from the amount applied.Initial all figures on this Total changes approved Application and r .,, ratan Sheet that are changed to conform with the amount certified.) in previous months by Owner ARCHIT= Total approved this Month By: 4 Date: TOTALS $0.00 $0.00 This Certificate is i c negotia e. The AMOUNT CERTIFIED is payable onl to t Uontrac or named erem tssu- ce,payment and acceptance of payment are s snout NET CHANGES by Change Order $0.00 prejudice o any r ghts of the Owner or Contractor under this Contract. AIA DOCUMENT G702 APPLICATION AND CERTIFICATION FOR PAYMENT-1992 EDITION.AIA ®1992 THE AMERICAN INSTITUTE OF ARCHITECTS,1735 NEW YORK AVE.,N.W.,WASH4NGTON,DC 20006-5292 Users may obtain validation of this document by requesting a completed AIA Document D401 -Certification of Document's Authenticity from the Licensee. P. SIGNATURE CONSTRUCTION LLC 720 3rd Avenue, S. W. Carmel, Indiana 46032 Application # 1 9/25/13 Nash Garage Carmel, Indiana Revised WORK COMPLETED TOTAL BALANCE TO DESCRIPTION OF SCHEDULED Change SCHEDULED FROM PREVIOUS THIS COMPLETED AND FINISH WORK VALUE Orders VALUE APPLICATIONS PERIOD STORED TO DATE % LESS RETAINAGE RETAINAGE General Conditions 92,161.00 92,161.00 0.00 57,644.46 57,644.46 63% 34,516.54 0.00 Construction Management Fee 64,615.00 64,615.00 0.00 14,215.30 14,215.30 22% 50,399.70 0.00 156,776.00 0.00 156,776.00 0.00 71,859.76 71,859.76 46% 84,916.24 0.00 ,a =AIA Document G732TM - 2009 Application and Certificate for Payment, Construction Manager as Adviser Edition TO OWNER: City of Carmel-Redevelopment Comm PROJECT: Parcel 9-54 Parking Garage&Ramp APPLICATION NO: ?,,. DISTRIBUTION TO: One Civic Square OWNER Carmel, IN 46032 PERIOD TO 9/20/13 CONSTRUCTION MANAGER _ — FROM Gibraltar Construction Corp VIA CONSTRUCTION CONTRACT DATE: 5/2/13 ARCHITECT — CONTRACTOR:, 2932 N.Webster Ave. MANAGER: PROJECT NOS: / / CONTRACTOR Indianapolis, IN 46219 — FIELD — CONTRACT FOR: Nash Parking Garage VIA ARCHITECT: OTHER _ The undersigned Contractor .ertifies that to the best of the Contractor's knowledge,information and CONTRACTOR'S APPLICATION FOR PAYMENT belief the Work covered by t . Application for Payment has been completed in accordance with the Application is made for payment,as shown below,in connection with the Contract. Contract Documents,that all i ounts have been paid by the Contractor for Work for which previous ALA Document G703TM,Continuation Sheet,is attached. Certificates for Payment wer: -.ued and payments received from the Owner,and that current payment 1.ORIGINAL CONTRACT SUM $ 1,476,000.00 shown herein is now due 2.NET CHANGES IN THE WORK $ 0.00 CONTRACTOR: Gib �Itar '+nstruction Corp 3.CONTRACT SUM TO DATE(Line I±2) $ 1,476,000.00 By: Date: 9 a /3 4.TOTAL COMPLETED AND STORED TO DATE(Column G on G703) $ 343,900 00 State of: IN,,Ill ' � 5.RETAINAGE: County of: �, '�'`� dkla�f� i�, MCBRIDE a. %of Completed Work Subscribed and• , -Pis bef. e ,. • {� (Column D+Eon G703) $ 34,390.00 me this , d, I t0 g. r1f Hancock Exp 11-29-2017 Co u my ( ) y°f ._ �►4 * M *fin Exp. 11-29-2019 b. %of Stored Material Notary Publ ry , N. , #611�2 (Column F on G703) $ Commission ex s DIP i Total Retainage(Lines 5a+5b,or Total in Column 1 on G703) $ CERTIFICATE FOR PAYMENT 6.TOTAL EARNED LESS RETAINAGE $ 309,510.00 In accordance with the Contract Documents,based on evaluations of the Work and the data comprising (Line 4 minus Line 5 Total) this application,the Construction Manager and Architect certify to the Owner that to the best of their 7.LESS PREVIOUS CERTIFICATES FOR PAYMENT 0.00 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 payment of the AMOUNT 8.CURRENT PAYMENT DUE $ 309,510.00 CERTIFIED. ex 9.BALANCE TO FINISH,INCLUDING RETAINAGE AMOUNT CERTIFIED $ l f (Attach explanation if amount certified differs from the amount applied.InitYa a l figures on this (Line 3 minus Line 6) $ 1,166,490.00 Application and on the Continuation Sheet that are changed to conform with the amount certified.) CONSTRUCTION MANAGER: . By: ., Date: SUMMARY OF CHANGES IN THE WORK ADDITIONS DEDUCTIONS ARCHITECT: I A i• Prime Contractors are responsible for performing portions of the Total changes approved in previous months by Owner $ $ Project, the • -ch ec:+ i•n is not required) Total approved this month including Construction By aiiI l b. Date: 2 r 27 Change Directives $ $ Th s Certi iae is of negotiab e ; e AMO ∎' CERTIFIED is payabl only to e Contractor named TOTALS $ $ her n.Issua ce,payment and acceptance of payment are without prejudice to any rights of the Owner NET CHANGES IN THE WORK $ or Co •r 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. AIA Document G732TM—2009(formerly G702T"CMa—1992).Copyright©1992 and 2009 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 Docu ents,e-mail The American Institute of Architects'legal counsel,copyright @aia.org. Chl 114-44,3 CONTINUATION SHEET Page 2 of 3 APPLICATION NO. : 1 APPLICATION AND CERTIFICATE FOR PAYMENT, containing Contractor's signed Certification, is APPLICATION DATE: 9/20/2013 attached. In tabulations below, amounts are stated to the nearest dollar. Use Column I on Contracts where variable retainage for line items may apply. PERIOD TO: 9/30/2013 ARCHITECT'S PROJECT NO. : A B C D E F G H I WORK COMPLETED MATERIALS TOTAL ITEM SCHEDULED FROM PREVIOUS PRESENTLY COMPLETED AND % BALANCE TO RETAINAGE N0. DESCRIPTION OF WORK VALUE APPLICATION THIS PERIOD STORED(NOT IN STORED TO DATE (G/C) FINISH (IF VARIABLE (D+E) D OR E) (D+E+F) (C-G) RATE) 1 Mobilization 25,000 $15,000.00 $15,000 60% 10,000.00 1,500 2 General Conditions 42,000 $16,500.00 $16,500 39% 25,500.00 1,650 3 Engineering and Layout 8,100 $6,400.00 $6,400 79% 1,700.00 640 4 Mass Excavation 135,000 $135,000.00 $135,000 100% - 13,500 5 Mass Backfill 86,000 $0 0% 86,000.00 - 6 Foundations- Material 52,000 $25,000.00 $25,000 48% 27,000.00 2,500 7 Foundations- Labor 42,000 21,000 $21,000_ 50% 21,000 2,100 8 Cast in Place Walls- Material 76,000 12,000 $12,000 16% 64,000 1,200 9 Cast in Place Walls- Labor 124,000 19,500 $19,500 16% 104,500 1,950 10 Elevator Pit- Material 2,000 $0 0% 2,000 - 11 Elevator Pit- labor 3,000 $0 0% 3,000 - 12 Slab on Grade- Material 41,000 $0 0% 41,000 - 13 Slab on Grade- Labor 31,000 $0 0% 31,000 - 14 Topping Slab- Material 55,000 $0 0% 55,000 - 15 Topping Slab- Labor 22,000 $0 0% 22,000 - 16 Metal Pan Stairs- Material 2,400 $0 0% 2,400 - 17 Metal Pan Stairs - Labor 6,500 $0 0% 6,500 - 18 Precast Hollow Core Planks 161,000 $0 0% 161,000 - 19 Masonry 142,000 $0 0% 142,000 - 20 Structural Steel Material 195,000 21,000 $21,000 11% 174,000 2,100 21 Structural Steel Labor 34,000 $0 0% 34,000 - 22 Earthwork and Site Utilities 85,000 $0 0% 85,000 - 23 Rebar Material 52,000 38,000 $38,000 73% 14,000 3,800 24 Rebar Install 29,000 9,500 $9,500 33% 19,500 950 25 Allowances 25,000 25,000 $25,000 100% - 2,500 $1,476,000 $0 $343,900 $0 $343,900 23% $1,132,100 $34,390 . . ISA Form # 1-402 :r` :a4• AFFIDAVIT AND WAIVER OF LIEN { ❑ FINAL ® PARTIAL N PAYMENT TO FOLLOW State of Indiana, County of Marion, SS Michael Smith being duly sworn state that he is the President of Gibraltar Construction Corp having contracted with the Owner to furnish certain materials and/or labor for a project known as Parcel 9-54 Garage & Ramp and owned by City of Carmel— Redevelopment Commission and does hereby further state on behalf of the aforementioned contractor: (PARTIAL WAIVER)that there is due from the Owner the sum of Three Hundred Nine Thousand Five Hundred Ten and No/100 Dollars ($0.00) n receipt of which is hereby acknowledged; or the payment of which has been promised as the sole consideration of this Affidavit and Partial Waiver of Lien which is given solely with respect to said amount, and which waiver shall be effective only upon receipt of payment thereof by the undersigned; (FINAL WAIVER) that the final balance due from the Owner is the sum of Dollars ($ .00) n receipt of which is hereby acknowledged; or n the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which shall become effective upon receipt of such payment. THERFORE, the undersigned waives and releases unto the Owner of said premises, any and all lien or claim whatsoever on the above-described property and improvements thereon account of LABOR or material or both, furnished by the undersigned thereto, subject to limitations of conditions e pressed herein, if any; and further certifies that no other party has any claim or right to a lien on account of any work oe 1 ormed or material furnished to the undersigned for said project, and within the scope of this affidavit and waiver. Gibraltar Construction Corp By d , Title President WITNESS MY HAND AND NOTORIAL SEAL, . , rd .' September, 2013. (Notary Public) °% BRIAN R. MCBRIDE C 1979 iNMANA SURCONTPACTOTIS ASSOCIATION INCCIRPOAAC(Q unswho-uect pepiO4vtlion P;Uh,13.letl Res. of Hancock County,. ,n,�, \*'.� My Comm, Exp. 11-29-2017 LPN Commission # 611862 CITY OF CARMEL TO: CONTRACT CHANGE ORDER NO.: 01 DATE: CA/OS/9-013 PROJECT NAME: PARCEL q-S`1 PAm3G n4$-AGE: AxJD &AMP CITY REQ. NO.: CITY PO NO.: CITY PO DATE: _ I. You are directed to make the following changes in this Contract: (Brief Description) it aSOO ALLatJ4,0CE. AY1 4o(1ZA4-nai) OemockciaG PtND 2C MaVAL OF UNSoiTABLESCHEDULED ADJUSTMENT So 1L5. ADP 5-ro,JE AiJO TE ITEM AMOUNT (+) OR (-) DAYS II. The following referenced Documents further describe the changes outlined in Paragraph I, and are to be considered a part of this Change Order: R.F.P.: W.D.C. No.: Other: The changes result in the following adjustment of Contract Price and Contract Time: Contract Price prior to this Change Order $ j q )(0 017 Contract Price will be increased/decreased by this Change Order $ 0 New Contract Price including this Change Order $ 1,99L,pccx Contract Time Prior to this Change Order Days Completion Date Net increased/decreased resulting from this Change Order Days Current Contract Time including this Change Order Days Completion Date This Change Order is for full and final settlement of all direct, indirect, impact costs and time extensions incurred at any time resulting from the performance of the changed work. The Above Changes Are The Above Changes Are Approved: Recommended Accepted: �g9 CI. (-fv4- Co,t\S{rucfN- ENGINEER ( I. 1,1 CONTRACTOR William Hammer, President �a (�°t a-43 D N, wQ4,s4-er Address ( Address David Bowers, Vice President , 1N LtC.1e1 City/Statef Zi Ak City/State/Zip Bradley Meyer, Secretary �,u By'■7 Pho -. 111 -70c-5; 79.7C\ Phone: S-75-- ssr Date: q 2y'- Date: It- 13 (3 Les Olds, AIA, Executive Dir. ATTEST: Diana Cordray, Clerk- Treasurer Date: AR-11 CITY OF CARMEL TO: GI MALTAfc CAN STR OCT log CONTRACT CHANGE REQUEST NO.: 01 DATE: cc/OS/ 013 PROJECT NAME: PARCEL 9-S`I PAK L cl G GARAGE A u 6 AArWP FROM: SIG/JAI-ORE COJSTR')CT1OR IT IS REQUESTED THAT A CONTRACT CHANGE BE MADE TO THE ABOVE REFERENCED CONTRACT. 1. SCOPE OF WORK (USE ADDITIONAL PAGES IF REQUIRED. ALSO LIST OTHER CONTRACTS INVOLVED.) 0ErnWu:10& Atib R1=MOVAL OF 0330 tT/\i LC SOILS App STOrje At3Q GOAJCRETE 2. REASON FOR CHANGE: SOIL Go►JA IN:x1S 3. APPROXIMATE COST CHANGE TO CONTRACT PRICE: tit a5ooe) AL) A,,kE 4. WILL THE CONTRACT NEED ADDITIONAL CONTRACT TIME TO COMPLETE THE CHANGE IN WORK SCOPE? -YES -NO -(CAL. DAYS) 5. WILL THE CONTRACTOR NEED ADDITIONAL PERSONNEL TO COMPLETE - THE CHANGE IN WORK SCOPE? -YES -NO IF NO, TRADE(S): NO. OF PERSONNEL: DURATION: 6. IDENTIFICATION OF ATTACHMENTS: DATE: DATE: PREPARED REVIEWED BY: SKIA)AiuRC REVIEWED BY: G0,JS-1.RQcc Lc)tJ ENGINEER Comments and Recommendation: /kint-ioRRAIL0/3 -r0 , .EuASE a50m0 ALt.tx.iA,XE AR-9 APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT G702 Page ONE of 2 pages TO(OWNER): Carmel Redevelopment Commission PROJECT: CCC-Parcel 9-54 Garage&Rar APPLICATION NO: 1 Distribution to: 30 W. Main Street, Suite 220 nOWNER Carmel, IN 46032 PERIOD TO: August 31,2013 nARCHITECT FROM: VIA(ARCHITECT): ARCHITECTS NO: []CONTRACTOR (Contractor) Robert Haines Company DE E l 911V OAA1333d PROJECT NO. 2747 N. Emerson Avenue RHC# 13C251 Q Indianapolis, IN 46218 CONTRACT FOR CONTRACT DATE : Application is made for payment, as shown below, in connection with the Contract. CONTRACTOR'S APPLICATION FOR PAYMENT Continuation Sheet,AIA Document G703, is attached. CHANGE ORDER SUMMARY 1.ORIGINAL CONTRACT SUM $210,000 Change orders approved in ADDITIONS DEDUCTIONS 2.Net change by Change Orders previous months by Owner 3.CONTRACT SUM TO DATE(Line 1+-2) $210,000 TOTAL 4.TOTAL COMPLETED&STORED TO DATE $28,425 Approved this Month (Column G on G703) Number Date Approved 5. RETAINAGE: a. 10 %of Completed Work $2,843 (Column D+E on G703) b. %of Stored Material Column F on G703) Total Retainage(Line 5a+5b or Approved this Month TOTALS Total in Column I of G703) $2,843 Net change by Change Orders 6.TOTAL EARNED LESS RETAINAGE $25,583 The undersigned Contractor certifies that to the best of the Contractors knowledge, (Line 4 less Line 5 Total) information and belief the Work covered by this Application for Payment has been 7.LESS PREVIOUS CERTIFICATES FOR completed in accordance with the Contract Documents,that all amounts have been PAYMENT(Line 6 from prior Certificate) paid by the Contractor for Work for which previous Certificates for Payment were 8.CURRENT PAYMENT DUE $25,583 issued and payments received from the Owner,and that current payment shown 9.BALANCE TO FINISH,PLUS RETAINAGE $184,418 herein is now due. (Line 3 less Line 6) CONTRACTOR Robert Haines Co. State of: Indiana County of: Mai ion Subscribed and showpfb rem is yy jJV'`" Aug 20,2013 . Notary Public: By // � Date. August 20 2013 My Commission expires: �` 1/16/20-17 4- . 13 AMOUNT CERTIFIED � , ,�;,,, ti ARC CT'S CERTIFICATE FOR PAYMENT (Attach explanation if amo n certified differs from the amount applied for.) . - � `^� I ordance with the Contract Documents,based on on-site observations and the ARCHITECT: ,- data comprising the above application, the Architect certifies to the Owner that to the -�, + best of the Architect's knowledge,information and belief the Work has progressed as B L l -■ Date: `',,,• G� 1t indicated,the quality of the Work is in accordanace with the Contract Documents,and This Certificate is no negotiabl•.' AMOUNT CERTI ED is payable only to the the Contractor is entitled to payment of the AMOUNT CERTIFIED. Contractor named he-in. Iss ,:n -,payment and acceptance of payment are without prejudice to any rights o -•-.• ner or Contractor under this Contract. Rev11/18194 AIA 13C251 CCC Parcel 9-54 Garage&Ramp 1 � �_� ���s X? CONTINUATION SHEET AIA DOCUMENT G703 Page 2 of 2 pages AIA Document G702,APPLICATION AND CERTIFICATE FOR PAYMENT,containing APPLICATION NUMBER 1 Contractor's signed Certification is attached. APPLICATION DATE: Aug 20,2013 In tabulations below, amounts are stated to the nearest dollar. PERIOD TO Aug 31,2013 Use Column 1 on Contracts where variable retainage for line items may apply. ARCHITECTS PROJECT NO A B C D E F G H I ITEM DESCRIPTION OF WORK SCHEDULED WORK COMPLETED MATERIALS TOTAL % BALANCE RETAINAGE NO. VALUE FROM THIS PERIOD PRESENTLY COMPLETED (G/C) TO FINISH PREVIOUS STORED AND STORED (C-G) APPLICATION (NOT IN TO DATE (D+E) D OR E) (D+E+F) 1 Submittals, Bonding&Insurance 7,500 3,000 3,000 40% 4,500 300 2 Firestopping 146,000 146,000 3 071700 Bentonite Waterproofing 56,500 25,425 25,425 45% 31,075 2,543 210,000 28,425 28,425 14% 181,575 2,843 Rev 11/18194 AIA 13C251 CCC Parcel 9-54 Garage&Ramp 1 SUBCONTRACTOR'S SWORN STATEMENT OF INDEBTNESS&CONDITIONAL WAIVER OF LIEN J/at /2(. E.) Being duly sworn upon his/her oath disposes and says that: 1. He/she is the Weer frr.S/DENT(inserting sole proprietor, partner or corporate office held, as the case maybe),of ROBERT HAINES CO.INC.(hereafter called the"Subcontractor"). He/she is over the age of twenty-one. He/she Is authorized to make this affidavit on behalf of Subcontractor. ..-- 2. Subcontractor is the 4/' 4X T &iS Subcontractor for the construction of the BUILDING development known as NASH BUILDING, loctited in_CARMEL (City), IN (state), hereafter referred to as the "Development", pursuant to the contract (the "Trade Contract") between the Subcontractor and Signature Construction,LLC,the General Contractor. 3. This affidavit is made for the express purpose of inducing Signature Construction, LLC, to make payment to Subcontractor In the amount of $ 25, 8'3. 60 representing Payment Application # / dated ,?d-13 for labor and materials furnished pursuant to said Trade Contract through this date. Upon receipt of said payment the Subcontractor shall be paid in full, exclusive of retainage, for all services, labor and materials furnished to, provided for or used in connection with the Development through the date noted above and hereby waives any lien rights to which Subcontractor Is entitled thro gh the above date. Subcontractor further acknowledges that upon receipt of said payment the receipt of$ to date. 4. Listed below are all suppliers or other persons who either has furnished or might furnish the Subcontractor with materials, appliances, machinery, fixtures or furnishing placed upon or Installed on the development. Mark(X) in the appropriate column for EACH supplier listed. Place an (X) In column: 1) If a waiver of lien by supplier conditioned by payment of a specified amount is attached hereto. (In this case also show the amount owed the supplier). 2.) If a FULL,(final) lien release has been signed and delivered to the General Contractor.3.) If the initial delivery has not been made. Supplier List(Add list if necessary) 1:Amount Owed 2 3 ml - �/Ei v en1 kE. P Ii #1 and 2 correspond to the same numbered choices on the waiver format. Signature Construction, LLC is hereby authorized to make payment to each such unpaid creditor either directly or by check jointly payable to Subcontractor and such creditor,as Signature Construction, LLC shall determine. 5.There are no bills, charges,costs or expenses for labor or material which could now or hereafter result in lien being filed against the Development or a claim being asserted against the General Contractor except the persons or businesses named in Paragraph 4 above. IN WITNE S WH E ,affiant has signed this document on behalf of the Subcontractor this ,?SZday of is ,20 1� uthorized resentative of Subcontractor) County of ) State of ) Subs ribed an sworn to before me, a Notary Public in and for said County and State,this 20 day of ,20 1 k (Notary Public) (R iinte4 Name) , ; My CommissiOin:Expires:`' '-. •`f7 NOTAY:SEAL`MUST'APPEAR-ON THIS FORM.