225868 11/05/2013 CITY OF CARMEL, INDIANA VENDOR: 367514 Page 1 of 1
ONE CIVIC SQUARE JBM CONTRACTORS CORP
CARMEL, INDIANA 46032 5299 W OLD 106TH ST CHECK AMOUNT: $96,434.50
ZIONSVILLE IN 46077 CHECK NUMBER: 225868
CHECK DATE: 11/5/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 3 96, 434 . 50 BUILD OUT
i
APPLICATION AND CERTIFICATION FOR PAYMENT
PAGE ONE OF 1 PAGES 2
TO OWNER: PROJECT: Proposed Renovations APPLICATION NO: 3 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 -_- ARCHITECT
Carmel,IN 46032 PERIODTO: 10/31/13 OCONTRACTOR
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 d that current payment shown herein is now due.
1 ORIGINAL CONTRACT SUM $ 164,918.00
2 Net change by Change Orders $ 14,338.00 CONTRACTOR:
3 CONTRACT SUM TO DATE(Line 1+2) $ 179,256.00 CONTRAcTO .
4 TOTAL COMPLETED&STORED TO $ 179,256.00
DATE (Column G on G703) By: U a e:
5 RETAINAGE: ICHAEL JOHN bTUERENbhKtU
a. 5 %of Completed Work State of- Junty of: ����
(Column D+E on G703) $ 8,962.80 Subscrib d and sworn"to before e t 's b. %of Stored Material Notary ublic:'j/ Notary Public, State of Indiana
(ColumnFonG703) $ My Commissionexpireses: y Commission Expires Feb.22,2020
Total Retainage(Line Sa+Sb or
Total in Column I of G703) $ 8,962.80 ARCHITECT'S CERTIFICATE FOR PAYMENT
6 TOTAL EARNED LESS RETAINAGE $ 170,293.20 In accordance with the Contract Documents,based on on-site obsemadons 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) $ 73,858.70 the quality of the Work is in accordance with the contract Documents,and the Contractor
8 CURRENT PAYMENT DUE $ 96,434.50 is entitled to payment of the AMOUNT CERTIFIED.
9 BALANCE TO FINISH,INCLUDING RETAINAGE $ 8,962.80 96,434.50
(Line 3 less Line 6) AMOUNT CERTIFIED.............................._...$ 96,434.50
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation if amount certified diiffersfrom the amount applied.Initial allfigures on this
Total changes approved in Application and on the Continuation Sheet that ore changed to conform with the amount certified.)
previous months by Owner 0.00 ARCHITECT:
Total aproved this Month 14,338.00 0.00 By: MAWR DESIGN, INC. Date: 10/30/2013
This Certificate is not negotiable.The AMOUNT CERTIFIED is payable only to the
TOTALS 14,338.00 0.00 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 14,338.00
CONTINUATION SHEEP
AIA DOCUMENT G703 u,srn,o;ons on reverse side) PAGE TWO OF TWO PAGES
AIA Document G702,APPLICATION AND CERTIFICATE FOR PAYMENT,containing APPLICATION NO.: 3
Contractor's signed Certification is attached. PERIOD T0: 10/31/13
In tabulations below,amounts are stated to the nearest dollar. PROJECT NO.S: JBM 13-18
Use Column I on Contracts where variable retainage for line items may apply.
A B C D E F G H I
SCHEDULED WORK MATERIALS TOTAL
VALUE COMPLETED PRESENTLY COMPLETED
FROM PREVIOUS STORED AND STORED BALANCE
ITEM DESCRIPTION OF ESTIMATED APPLICATION (NOT IN TO DATE % TO FINISH S-0%
NO. WORK COST (D+E) THIS PERIOD D OR E) (D+E+F) (G:C) (C-G) RETAINAGE
Division 1-General Conditions
1 General Conditions-material 4,930 3,697.50 1,232.50 0.00 4,930.00 100% 0.00 246.50
2 General Conditions-labor 950 712.50 237.50 0.00 950.00 100% 0.00 47.50
3 Supervision 6,000 4,500.00 1,500.00 0.00 6,000.00 100% 0.00 300.00
4 OH&P 16,985 12,738.75 4,246.25 0.00 16,985.00 100% 0.00 849.25
DIVISION 2-Site Constructlon
7 Demolition 9,000 9,000.00 0.00 0.00 9,000.00 100% 0.00 450.00
Division 4-Masonry
8 Stone Veneer 0 0.00 0.00 0.00 0.00 100% 0.00 0.00
DIVISION 6-WOODS&PLASTICS
11 framing 11,500 11,500.00 0.00 0.00 11,500.00 100% 0.00 575.00
12 finish carpentry 0 0.00 0.00 0.00 0.00 100% 0.00
13 Casework 4,150 0.00 4,150.01) 0.00 4,150.00 100% 0.00 207.50
DIVISION 8-DOORS&WINIDOWS 0.00
17 steel doors and frames 5,970 2,985.00 2,985.00 0.00 5,970.00 100% 0.00 298.50
18 labor 2,700 1,350.00 1,350.00 0.00 2,700.00 100% 0.00 135.00
Glass and Glazing 10,900 0.00 10,900.00 0.00 10,900.00 100% 0.00 545.00
DIVISION 9-FINISHES 0.00
19 drywall/gypsum board 14,500 ` 0.00 14,500.00 0.00 14,500.00 100% 0.00 725.00
Acoustical celfing,- 6,000 0.00 6,000.00 0.00 6,000.00 100% 0.00
20 Flooring 23,400 0.00 23,400.00 0.00 23,400.00 100% 0.00 1,170.00
21 painting and staining 5.900 0.00 5,900.00 , 0.00 5,900.00 100% 0.00 295.00
' DIVISION 10-SPECIALTIES 0.00
22 toilet and bath accessories 0 0.00 0.00 0.00 0.00 100% 0.00 0.00
23 fire extinguishers-wall mounted 10Ibs 300 0.00 300.00 0.00 300.00 100% 0.00 15.00
24 labor 50 0.00 50.00 0.00 50.00 100% 0.00 2.50
DIVISION 22-PLUMBING 0.00
25 Plumbing rough and finish 3,050 2,287.50 762.50 MILD 3,050.00 100% 0.00 152.50 �
26 Fire Suppression' 5,450 4,087.50 1,362.50 0.00 5,450.00 100% 0.00 272.50
DIVISION 23-HVAC 0.00
27 HVAC Rough and Finish 11,683 8,762.25 2,920.75 0.00 11,683.00 100% 0.00 584.15
DIVISION 26-ELECTRICAL i 0,00
28 Electrical rough in and Finish 21,500 16,125.00 5,375.00 0.00 21,500.00 100% 0.00 1,075.00
29 C081-26 Conduits 1,450 0.00 1,450.00 0.00 1,450.00 100% 0.00 72.50
30 CO42-Add base cabinet 325 0.00 325.00 0.00 325.00 100% 0.00 16.25
31 CONS-Electrical work 1,595 0.00 1,595.00 0.00 1,595.00 100% 0.00 79.75
32 CON4-Paint corridor&ceiling 825 0.00 825.00 0.00 825.00 100% 0.00 41.25
33 CO45-Fire resistant wrap 6,523 0.00 6,523.00 0.00 6,523.00 100% 0.00 326.15
34 COil6-Lights,switches and doors 3,620 0.00 3,620.00 0.00 3,620.00 100% 0.00 181.00
179,256.00 77,746.00 101,510.00 0.00 179,256.00 100.0% 0.00 8,662.80
AIA DOCUMENT G702 APPLICATION AND CERTIFICATE FOR PAYMENT 1992 EDITION AIA 1992THE AMERICAN INSTITUTE OF ARCHITECTS,1735 NEW YORK
AVENUE;N.W.,WASHINGTON,D.C.20006-5292
G703-1992
1 oft
f
iiil im
CONTRACTORS CORP.
WAIVER OF LEIN
PARTIAL /FINAL (circle one)
PROJECT: Proposed Renovations-Second Floor Unit Located 30 W.Main St.-Contract No.91
OWNER: City of Carmel,Indiana-Board of Public Works and Safety
JBM CONTRACT HOLDER: Board of Works and Public Safety
CONTRACT DATE:August 7th,2013
In consideration of the receipt of this partial/final (circle one) payment of 59.6;'40^0'_'(Ninety Six Thousand Four Hundred Thirty
Four Dollars and Fifty Cents)and all previous payments to the undersigned,the undersigned hereby waives and releases any and all
statutory and equitable liens and rights, if any, to claim or file notice of liens as to or on the above-described Premises and/or
Project on account and labor, work, material, machinery or equipment furnished or leased by or through the undersigned for the
construction or making of improvements on said Premises and/or Project, including all extras and additions furnished by the
undersigned, or to demand or receive any additional sums or payments with regard to such work or material supplied.
To induce the Owner to rely on this Partial/ Final (circle one) Waiver of Lien,the undersigned hereby waives any and all rights or
equitable defenses that might defeat this waiver.The undersigned hereby indemnifies and holds Owner harmless from and against
all liens, claims, expenses,damages and liabilities (including attorney's fees) asserted by any person or entity or incurred by Owner
on account of labor,work,material,machinery or equipment furnished or leased by or through the undersigned for the construction
of making improvements on said Premises and/or Project,including all extras and additions furnished by the undersigned.
The Undersigned hereby grants owner the right to sign and record notice of Partial/Final(circle one)termination.
IN WITNESS WHEREOF, the undersigned has executed this this Partial / Final (circle one) Waiver of Lien this 25th day of October,
2013.
i
i
CONTRACTOR
_JB actor rporation
By
`z I V
STATE OF )
)SS.
COUNTY OF )
Before me,a Notary Public in and for the State of Indiana, personally appeared Jeff Hammersley,the Ex.VP of JBM
Contractors Corp,who,having been duly sworn, acknowledged the execution of the foregoing this Partial/Final(circle one)Waiver
of Lien as such Executive VP for and on behalf of said Corporation .
WITNFS tom# is 7th day of September,2013.
MICHAEI.JGSEAL ERENBERG
Notary Public,State of Indiana Notary Public
My Commission Expires Feb.22,2020
_.. ._. . Printed-
My Commission Expires:
x - 77- 20�
I am a resident of
c(
County,_ 1:-
ounty,_1:- c&.2v-
I
Prescribed by State Board of Accounts
Form No.301-S(Rev.1997) ACCOUNTS PAYABLE VOUCHER
TO
ADDRESS 5(9 )9 D LJ 1 �o•uSuf��� �1"� �(
Invoice Date Invoice Number Item Amount
U nl5'�LuC-714w Sb
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 e t
(V(Q L) 00 c�
Mo. Day Yr. Signature Title
I hereby certify that the attached invoice(s), or bill(s), is (are)true an cqrreo and I have audited same in accordance
with IC 5-11-10-1.6.
Mo. Day Yr. Officeff Title
Voucher No. Warrant No.
ACCOUNTS PAYABLE DETAILED ACCOUNTS
MUNICIPAL WASTEWATER UTILITY ACCT.
CARMEL, INDIANA NO
So�199 w O�-D iO(o+"
ZIDA,)
Total Amount of Voucher $
Deductions
7
D. Ofj
Amount of Warrant $
Month of KW (Xr-
Acct.
VOUCHER RECORD No.
Collection System
Pumping
Treatment&Disposal
Customer Accounts
Administrative&General
Reclaimed Water Treatment
Reclaimed Water Distribution
Total
Allowed
Board Members
Filed
BOYCE FORMS•SYSTEMS 7.800-382-8702 325