224950 10/08/2013 CITY OF CARMEL, INDIANA VENDOR: 367514 Page 1 of 1
0 ) ONE CIVIC SQUARE JBM CONTRACTORS CORP CHECK AMOUNT: $48,906.00
CARMEL, INDIANA 46032 5299 W OLD 106TH ST
ZIONSVILLE IN 46077 CHECK NUMBER: 224950
CHECK DATE: 10/8/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 2 48, 906 . 00 OTHER EXPENSES
F �
9
1
1 -..
APPLICATION AND CERTIFICATION FOR PAYMENT PAGE ONE OF 1 PAGES 2
TO OWNER: PROJECT: Proposed Renovations APPLICATION NO: 2 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 F xxx ARCHITECT
Carmel,IN 46032 PERIOD TO: 9130/13 CONTRACTOR '
FROM CONTRACTOR: VIA ARCHITECT: MAWR Design,Inc.
JBM Contractors Corp 849 South Park Drive
5299 W Old 106th Street Carmel,Indiana PROJECT NOS: IBM 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.j
1 ORIGINAL CONTRACT SUM $ 164,918
2 Net change by Change Orders $ 0 CONTRACTOR:
3 CONTRACT SUM TO DATE(Line 1+2) $ 164,918 CONTRACTOR•
4 TOTAL COMPLETED&STORED TO $ 77,746
—7 )11/
DATE (Column G on G703) By: Otte:_
5 RETAINAGE:
a. 5 %of Completed Work State of: MHAEL JOHN 3TUERENBERG
(Column D+Eon G703) $ 3,887 - Subscribed and sworn to before fat/t1t1/s/ � day o p 1 .
b. %of Stored Material Notary PUbli Notary PUbIIC, State of Indiana
(Column F on G703) $ My Commis o/n ex_p"f My Commfsslon Expires Feb.22,2020
Total Retainage(Line 5a+5b or
Total in Column I of G703) $ 3,887 ARCHITECT'S CERTIFICATE FOR
6 TOTAL EARNED LESS RETAINAGE $ 73,859 to accordance with the Contract Documents,based on 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 belief the Work has progressed as indicated,
PAYMENT(Line 6 from prior Certificate) $ 24,953 the quality of the Work is in accordancewith the Contract Documents,and the Contractor
8 CURRENT PAYMENT DUE $ 48,906 is entitled to payment of the AMOUNT CERTIFIED.
9 BALANCE TO FINISH,INCLUDING RETAINAGE $ 91,059
(Line 3 less Line 6) AMOUNT CERTIFIED...................................$ 48,906
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanationi/amount certified diJJersJmm the amount applied.Initial allfiguresanthis
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 0 By: Date:
This Certificate is not negotiable.The AMOUNT CERTIFIED is payable only to the
TOTALS 0 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
VOUCHER # 136532 WARRANT # ALLOWED
367514 IN SUM OF $
JBM CONTRACTORS
5299 W Old 106th st ;
Zionsville, IN 46077
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
2 01-7360-08 $48,906.00
Voucher Total $48,906.00
Cost distribution ledger classification if
claim paid under vehicle highway fund
Prescribed by State Board of Accounts City Form No.201 (Rev 1995)
ACCOUNT'S PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show, kind of service, where
performed, dates of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
367514
JBM CONTRACTORS Purchase Order No.
5299 W Old 106th st Terms
Zionsville, IN 46077 Due Date 10/2/2013
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
10/2/2013 2 $48,906.00
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
i
Date Officer