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Home My WebLink AboutPayment app No. 4 Meridian Sr. Center ICDBG 04-III-1-SR LETTER OF TRANSMITTAL DATE: 26 August 2005 RECEIVED ATTN: company: address: fax phone JOB NAME: JOB NO.: RE: JOHNSON ARCHITECTS a professional corporation WILL BERG AUG 2 9 2005 CITY OF MERIDIAN 33 E. Idaho Ave. Meridian, ID 83642 208.888.4218 208.888.4433 City of Meridian City Clerk Office 440 e. c°'P°me drive, ste. 102 merid¡an,idaho 83642 Meridian Senior Center Remodel 04167 PAY APPLICATION NO. 4 -- WE ARE SENDING YOU: VIA: hand delivery #OF TYPE OF DATE DATE DESCRIPTION COPIES CORRESPONDENCE REVISED 3 Pay Application No. 4 1 Copy of Certificate of Occupancy THESE ARE TRANSMITTED: IS] For approval DFor your use OAs requested 0 For review and comment 0 Approved as submitted 0 Approved as noted 0 Returned for corrections 0 For your record 0 Resubmit copies for approval 0 Submit copies for distribution 0 Return corrected prints 0- REMARKS : TRANSMITTED BY: phone 208.846.9033 fax 208.846.9475 COpy TO: File, p:\projects\O4 I 67-meridian senior center upgrades\transmitta1s\comwb - 009.doc City of Meridian City Clerk OffiCe JOHNSON ARCHITECTS a professional corporation RECEIVED AUG 2 9 2005 August 26, 2005 440 e. corporate drive, ste. 102 meridian, idaho 83642 t208.846. 9033/£208.846. 9475 City of Meridian 33 E. Idaho Ave. Meridian, ill 83642 Attn: Will Berg Re: Meridian Senior Citizens Center Payment Application and Certification No.4 Will, Attached are three copies of KMO's Payment Application No.4. Please forward one copy to KMO after review and approval. We have reviewed this Payment Application and the CUITent progress of the work. To the best of our knowledge we agree that this Payment Application reasonably represents the construction progress. We recommend payment in the amount of$3,8l6.81. Please call if you have any questîon¡;¡. . JOHNSO TECTS, P.c. Walter Lindgren, Architect Enclosures: (3) copies of Certificate for Payment p:\projects\O4167 -meridian senior center upgrndes\ca\pay apps\pay app 04.doc "" ,... P A YM E NT APP LI CATION Page 1 TO: CITY OF MERIDIAN 33 E.IDAHOAVENUE MERIDIAN IDAHO 83642 WIL BERG KMO INC 923 16TH AVENUE SOUTH,SUITE-A NAMPA IDAHO 83651 MERIDIAN SENIOR CENTER REMODEL FROM: FOR: CONTRACTOR'S SUMMARY OF WORK Application is made for payment as shown below. Continuation Page is attached. 1. CONTRACT AMOUNT 2. SUM OF ALL CHANGE ORDERS 3. CURRENT CONTRACT AMOUNT 4. TOTAL COMPLETED AND STORED (Column G on Continuation Page) 5. RETAINAGE: a. 5.00% of Completed WorK (Columns D + E on- Continuation Page) b. 5.00% of Material Stored (Column F on Continuatíon Page) Total Retainage (line 5a + 5b or Column I on Continuation Page) (line 1 +/- 2) PROJECT PO# 25-79 MERIDIAN SENIOR NAME AND MERIDIAN SENIOR CENTER REMODEL LOCATION: 133 BROADWAY AVE, MERIDIAN 1083642 APPLICATION # PERIOD THRU: PROJECT #5: DATE OF CONTRACT: 4 Distribution to: 08116/2005 DOWNER P0#25-79 0 ARCHITECT 04/25/2005 D CONTRACTOR 0 0 ARCHITECT: JOHNSON ARCHITECTS 440 E. CORPORATE DRIVE SUITE #102 MERIDIAN IDAHO 83542 $93,000.00 $3,987.56 $96,987.56 $96,987.56 $4,649.63 $199.75 6. TOTAL COMPLETED AND STORED LESS RETAINAGE (Line 4 minus Une 5 Total) 7. LESS PREVIOUS PAYMENT APPLICATIONS 8. PAYMENT DUE 9. BALANCE TO COMPLETION (Line 3 minus Line 6) $4,849.38 ADDITIONS SUMMARY OF CHANGE ORDERS Total changes approved in previous months Tota! approved this month TOTALS NET CHANGES PAYMENT APPLlCAT!ON $3,987.56 $0.00 $3,987.56 $3,987.56 $4,849.38 $92,138.18 $88,321.37 $3,816.81 I DEDUCTIONS $0.00 $0.00 $0.00 By: Contractor's signature that (1) the Work h previously paid to..(:o materials and legally en" is his assurance to Owner, concerning the payment herein applìed for, en~rmed as required in the Contract Documents, (2) all sums cto r the Contract have been used to pay Contractor's costs for labor, y: ~ u der the Contract for Wt°rk previously paid for, and (3) Contrador is - ,\\,,\Iiltl.'f( '... .. " \,.\',.' " ,", ( ,." ,. Date: ,/ '~16;~0Q6 . , , , , 'I, !' \' I I " !I',' t.. ,'-!', : ! Jo.' ," ',I , ,,; I' , , , , (, / /"~' ,.¡ , ',:",,::;\<~ . State of: County of: Subscribed and sworn to before me this day of Notary Public: My Commission Expires: ARCHITECT'S CERTI FICA TION Architect's signature below ìs his assurance to OWner, concerning the payment herein applied for, that: (1) Architect has inspected the Work represented by this Application, (2) such Work has been completed to the extent indicated in thís Application, and the quality of workmanship and materials conforms with the Contract Documents, (3) this Application for Payment accurately states the amount of Work completed and payment due therefor, and (4) Architect knows of no reason why payment should not be made. CERTIFIED AMOUNT......................................................................................... ~ B/¿' a I , (If the certified amount is different from the payment due, you should attach an expla tion, Initial all the figures that are cfJJlr1ged ta match the certified amount.) ARCHITECT: By: Date: J."Z/I-P'5 Neither this Ap cati payment applied for herein is assignable or negotiable, Payment shall be made only to Cont 0, nd is without prejudice to any rights of Owner or Contractor under the Contract Documents: erwíse. ass, INC. DOCUMENT '. - ,- . .. '" CONTINUATION PAGE Page2of 3 PROJECT: PO# 25-79 MERIDIAN SENIOR APPLICATION #: 4 MERIDIAN SENIOR CENTER REMODEL DATE OF APPLICATION: 08J16f2005 Payment Application contaíning Contractor's sígnature is attached. PERIOD THRU; 0811612005 PROJECT #5: P0#25-79 A B C D E F G H I COMPLETED WORK STORED TOTAL % BALANCE SCHEDULED ITEM # WORK DESCRIPTION AMOUNT AMOUNT AMOUNT MATERIALS COMPLETED AND COMPo TO RET AlNAGE PREVIOUS THIS PERIOD (NOT IN D OR E) STORED (GfC) COMPLETION (If Variable) PERIODS (D+E+F) (C-G) 1. [NO FEE $2,790.00 $2,790.00 $0.00 $0.00 $2,790.00 100% $0.00 2. OBIUZATtON $1,000.00 $1,000.00 $0.00 $0.00 $1,000.00 100% $0.00 3. SUPERVISION $2,500.00 $2,500.00 $0.00 $0.00 $2,500.00 100% $0.00 4. TEMPORARY FACIL1TIES $1,500.00 $1,500.00 $0.00 $0.00 $1,500.00 100% $0.00 5. EXCAVA TtON-CONCRETE $8,000.00 $8,000.00 $0.00 $0,00 $8,000.00 100% $0.00 6. METAL HANDRAil-LINTEL $7,000.00 $7,000.00 $0.00 $0.00 $7,000.00 100% $0.00 7. SAWCUTTING $400,00 $400.00 $0.00 $0.00 $400.00 100% $0.00 8. SELECTIVE DEMOLITION $4,800.00 $4,800.00 $0.00 $0.00 $4,800.00 100% $0.00 9. EPOXY & REBAR $250.00 $250.00 $0.00 $0.00 $250.00 100% $0.00 10. ROUGH CARPENTRY $4,000.00 $4,000.00 $0.00 $0,00 $4,000.00 100% $0.00 11. UMBER.MA TERIALS $1,400.00 $1,400.00 $0.00 $0.00 $1,400.00 100% $0.00 12. MASONRY $800.00 $800.00 $0.00 $0.00 $800.00 100% $0.00 13. ELECTRICAL $8,400.00 $6,720.00 $1,680.00 $0.00 $8,400.00 100% $0.00 14. MECHANICAL $4,600.00 $3,680,00 $920.00 $0.00 $4,6û0.00 100% $0.00 15. PLUMBING $10,000.00 $10,000.00 $0.00 $0,00 $10,000.00 100% $0.00 16. FIRE SPRINKLERS $7,834.00 $7,834.00 $0,00 $0.00 $7,834.00 100% $0.00 SUB-TOTALS $65,274.00 $62,674.00 $2,600.00 $0.00 $65,274.00 100% $0.00 CONTINUATION PAGE FOR PAYMENT APPLICATION ass, INC. DOCUMENT 1- '.' ~~~TlNÜA TION PAGE Page 3 of 3 ! PROJECT: PO# 25-79 MERIDIAN SENIOR MERIDIAN SENIOR CENTER REMODEL APPLICATION #: DATE OF APPLICATION: PERIOD THRU: PROJECT 1$: 4 08t1612005 08I16t2005 PO#25-79- Payment Applícation containing Contractor's signature is attached. A B C 0 E F G H I COMPLETED WORK STORED TOTAL % BALANCE ITEM # WORK DESCRIPTION SCHEDULED AMOUNT AMOUNT MATERIALS COMPLETED AND COMPo TO RETAINAGE AMOUNT PREVIOUS THIS PERIOD (NOT IN D OR E) STORED (Gte) COMPLETION (If Variable) PERIODS (D+E+F) (C-G) 17. INSUlATION $350.00 $350.00 $0.00 $0.00 $350.00 100% $0.00 18. DRYWALL $2,200.00 $2,200.00 $0.00 $0.00 $2,200.00 100% $0.00 19. PAINTtNG $4,610.00 $3,688.00 $922.00 $0.00 $4,610.00 100% $0.00 20. !vINYL FLOORING $400.00 $400.00 $0.00 $0.00 $400.00 100% $0.00 21. CERAMIC TILE $9,957.00 $9,957.00 $0.00 $0.00 $9,957.00 100% $0.00 22. FINISH CARPENTRY $BOO.OO $MO.OO $0.00 $0.00 $BOO. 00- 100% $0.00 23. DOORS & HARDWARE $3,007.00 $1,206.30 $300.70 $1,500.00 $3,007.00 100% $0.00 24. ¡GlAZING $250,00 $125.00 $125.00 $0.00 $250.00 100% $0.00 25. BATH PARTITIONS $2,000.00 $400.00 $0.00 $1,600.00 $2,000.00 100% $0.00 26. BATH ACCESSORIES $1,226.00 $331.00 $0.00 $895.00 $1,226.00 100% $0.00 27. FRP $2,576.00 $2,576.00 $0.00 $0.00 $2,576.00 100% $0,00 28. JANITORIAL $350.00 $280.00 $70.00 $0.00 $350.00 100% $0.00 29. CHANGE ORDER #1 $3,987,56 $3,987.56 $0.00 $0.00 $3,987.56 100% $0.00 TOTALS $96,987.56 $88,974.86 $4,017.70 $3,995.00 $96,987.56 100% $0.00 CONTINUATION PAGE FOR PAYMENT APPLICATION QSS, INC. DOCUMENT Cfl;rM¡!¡ ~', \":':"'.o..;<.:.;=~::~:: -' CITY OF MERIDIAN CERTIFICATE OF OCCUPANCY Permit '# BP2005-6'r 7 91512005 Applicant: Meridi,en $81'1101' CItizens Center Parcel Number: PARC2001 ~ 1529 Contractor: 7':> Be DETERMINED KffO ~ÒJ1stYtlcf¡ó~ c,/{¡Pl-.:< (Pi? c¡ Address: "133 Broadway Ave. W. Subdivision: Lot(s) Block ProjDesc: \)erldiar: S$l'!ior 'Ziti:$r".$ Ctnter Purpo$e: -; en ant! mprOlfement StructUse: ::on".mercial JobValue;$90,OOO,QC LìvíngSpace: ßsmùStor: Ga~ge~ Structure Area: 5 .495,00 Certificates of occupancy must be posted in a conspicuous place when the occupancy of the structure is other than residential. APPLI~~æ::.7\PPRO V ALS ..., ~Vþ¡ <T-1-oL ~~ . 0 / ¿;/ Building Department I-~ OCCUPANCY REQUIREMENTS Deviation from the approved occupancy for which this certificate has been issued is unlawful. N/~ ¡J/A Planning and Zoning The issuance of a Certificate of Occupancy shall not be construed as an approval of a violation of the provisions of the Meridian City Building and Fire Codes or of other ordinances of this jurisdiction. Engineering Department c?~ /-, - EP~~- Fire Department AI"ser-revised 5/21/03 ~ PAYMENT APPLICATION TO: CITY OF MERIDIAN 33 E. IDAHO AVENUE MERIDIAN IDAHO 83642 Wil BERG KMO INC 92316TH AVENUE SOUTH,SUITE-A NAMPA IDAHO 83651 MERIDIAN SENIOR CENTER REMODEL FROM: FOR: CONTRACTOR'S SUMMARY OF WORK Application is made for payment as shown below. Continuation Page is attached. 1. CONTRACT AMOUNT 2. SUM OF ALL CHANGE ORDERS 3. CURRENT CONTRACT AMOUNT 4. TOTAL COMPLETED AND STORED (Column G on Continuation Page) 5. RETAINAGE: a. 5.00% of Completed Work (Columns D + E on Continuation Page) b. 5.00% of Material Stored (Column F on Continuation Page) Total Retainage (line 5a + 5b or Column I on Continuation Page) (line 1 +/- 2) PROJECT NAME AND LOCATION: Page 1 PO# 25~79 MERIDIAN SENIOR MERIDIAN SENIOR CENTER REMODEL 133 BROADWAY AVE, MERIDIAN ID 83642 APPLICATION it- PERIOD THRU: PROJECT #s: 4 Dístribulion to: 08116/2005 0 OWNER P0#25-79 0 ARCHITECT 04/2512005 0 CONTRACTOR 0 0 DATE OF CONTRACT: ARCHITECT: JOHNSON ARCHITECTS 440 E. CORPORATE DRNE SUITE #102 MERIDIAN IDAHO 83642 $93,000.00 $3,987.56 $96,987.56 $96,987.56 $4,649.63 $199.75 6. TOTAL COMPLETED AND STORED LESS RETAINAGE (line 4 minus line 5 Total) 7. LESS PREVIOUS PAYMENT APPLICATIONS 8. PAYMENT DUE 9, BALANCE TO COMPLETION (Line 3 minus line 6) $4,849.38 ADDITIONS SUMMARY OF CHANGE ORDERS Total changes approved in previous months Total approved this month TOTALS NET CHANGES PAYMENT APPLICATION $3,987.56 $0.00 $3,987.56 $3,987,56 $4,849.38 $92,138.18 $88,321.37 I $3,816.81 I DEDUCTIONS $0.00 $0.00 $0,00 By: is his assurance to Owner, concerning the payment herein applied for, ""~m'd so ~q"i~d I, th, C'"t~ct Do~m..ts, (2) .11 ,"m, facto r the Contract have been used to pay Contractor's costs for labor, gy~ ~ u der the Contract for WOjreViOUSIY paid for, and (3) Contractor is ~ Date: 08/1612005 State of. County of: Subscribed and sworn to before me this day of Notary Public: My Commission Expires: ARCH ITECT'S CERTI FICA TION Architect's signature below is his assurance to Owner, concerning the payment herein applied for, that: (1) Architect has inspected the Work represented by this Applìcation, (2) such Work has been completed to the extent indicated in this Application, and the quality of workmanship and materials conforms with the Contract Documents, (3) this Application for Payment accurately states the amount of Work completed and payment due therefor, and (4) Architect knows of no reason why payment should not be made. CERTIFIED AMOUNT..................................................................... ....................,~, ø/~ .IJI . (If the certifœd amount is different frol1J.Jtle payment due, you should attach an explanation. Initial all the figures that are chenfJ1il/llfõnatctathe cerüfied amount.) ARCHITECT: By: Date: ~'2-~ ,p:) applied for herein is assignable or negotiable. Payment shall thout prejudice to any rights of Owner or Contractor under ass, INC. DOCUMENT ,.-, , CONTINUATION PAGE Page 2 of 3 PROJECT: PO# 25-79 MERIDIAN SENtOR MERIDIAN SENIOR CENTER REMODEL APPLICATION#: DATE OF APPLICATION: PERIOD THRU: PROJECT #s: 4 08/1612005 08/16/2005 P0#25-79 Payment Application containing Contractor's signature is attached. A B C D I E F G H I COMPLETED WORK STORED TOTAL % BALANCE ITEM # WORK DESCRIPTION SCHEDULED AMOUNT AMOUNT MATERIALS COMPLETED AND COMPo TO RETAI NAG E AMOUNT PREVIOUS THIS PERIOD (NOT IN D OR E) STORED (G/C) COMPLETION (If Variable) PERIODS (D + E + F) (C-G) 1. BOND FEE $2,790.00 $2,790.00 $0.00 $0.00 $2,790,00 100% $0.00 2, MOBILIZATION $1,000.00 $1,000.00 $0.00 $0.00 $1,000.00 100% $0.00 3. SUPERVISION $2,Soo.00 $2,500.00 $0.00 $0.00 $2,500.00 100% $0.00 4, TEMPORARY FACILITIES $1,SOO.00 $1,500.00 $0.00 $0,00 $1,500,00 100% $0.00 5. EXCAVATION-CONCRETE $8,000.00 $8,000.00 $0.00 $0.00 $8,000.00 100% $0.00 6. METAL HANDRAIL-LINTEL $7,000.00 $7,000.00 $0.00 $0.00 $7,000.00 100% $0.00 7. SAWCUTTING $400,00 $400.00 $0.00 $0,00 $400.00 100% $0.00 8. SELECTIVE DEMOLITION $4,800.00 $4,800.00 $0.00 $0.00 $4,800.00 100% $0.00 9. EPOXY & REBAR $2S0.00 $2S0.00 $0.00 $0.00 $250.00 100% $0.00 10. ROUGH CARPENTRY $4,000.00 $4,000.00 $0.00 $0.00 $4,000.00 100% $0.00 11, LUMBER-MA TERIALS $1,400.00 $1,400.00 $0.00 $0.00 $1,400.00 100% $0.00 12. MASONRY $800.00 $800.00 $0.00 $0.00 $800.00 100% $0.00 13. ELECTRICAL $8,400.00 $6,720.00 $1,680.00 $0.00 $8,400.00 100% $0,00 14. MECHANICAL $4,600.00 $3,680.00 $920.00 $0.00 $4,600,00 100% $0.00 1S, PLUMBING $10,000.00 $10,000.00 $0.00 $0.00 $10,000.00 100% $0.00 16. FIRE SPRINKLERS $7,834.00 $7,834.00 $0.00 $0.00 $7,834.00 100% $0.00 SUB-TOTALS $65,274.00 $62,674.00 $2,600.00 $0.00 $65,274.00 100% $0.00 CONTINUATION PAGE FOR PAYMENT APPLICATION ass, INC. DOCUMENT -' , ,þtiIIIiì -' CONTINUATION PAGE Page 3 of 3 PROJECT: PO# 25-79 MERIDIAN SENIOR MERIDIAN SENIOR CENTER REMODEL APPLICATION #: DATE OF APPLICATION: PERIOD THRU: PROJECT #5: 4 08/1612005 08/1612005 PO#25-79 Payment Application containing Contractor's signature is attached. A 8 C D E F G H I COMPLETED WORK STORED TOTAL % BALANCE ITEM # WORK DESCRIPTION SCHEDULED AMOUNT AMOUNT MATERIALS COMPLETED AND COMPo TO RETAI NAG E AMOUNT PREVIOUS THIS PERIOD (NOT IN DOR E) STORED (G/C) COMPLETION (If Variable) PERIODS (D+E+F) (C-G) 17. INSULATION $350.00 $350.00 $0.00 $0.00 $350.00 100% $0.00 18. DRYWALL $2,200.00 $2,200.00 $0.00 $0.00 $2,200.00 100% $0.00 19. PAINTING $4,610.00 $3,688.00 $922.00 $0.00 $4,610.00 100% $0.00 20. !vINYL FLOORING $400.00 $400.00 $0.00 $0.00 $400.00 100% $0.00 21. CERAMIC TILE $9,957.00 $9,957.00 $0.00 $0.00 $9,957.00 100% $0.00 22. FINISH CARPENTRY $800.00 $800.00 $0.00 $0.00 $800.00 100% $0.00 23. DOORS & HARDWARE $3,007.00 $1,206.30 $300.70 $1,500.00 $3,007.00 100% $0.00 - 24. GLAZING $250,00 $125.00 $125.00 $0.00 $250.00 100% $0.00 25. BATH PARTITIONS $2,000.00 $400.00 $0.00 $1,600.00 $2,000.00 100% $0.00 26. BATH ACCESSORIES $1,226.00 $331.00 $0.00 $895.00 $1,226.00 100% $0.00 27. FRP $2,576.00 $2,576.00 $0.00 $0.00 $2,576.00 100% $0.00 28. JANITORIAL $350,00 $280.00 $70.00 $0.00 $350.00 100% $0.00 29. CHANGE ORDER #1 $3,987.56 $3,987.56 $0.00 $0.00 $3,987.56 100% $0.00 TOTALS $96,987.56 $88,974.86 $4,017.70 $3,995.00 $96,987.56 100% $0.00 CONTINUATION PAGE FOR PAYMENT APPLICATION ass, INC. DOCUMENT ~. PAYMENT APPLICATION TO: CITY OF MERIDIAN 33 E. IDAHO AVENUE MERIDIAN IDAHO 83642 WIL BERG KMOINC 923 16TH AVENUE SOUTH,SUITE-A NAMPA IDAHO 83651 MERIDIAN SENIOR CENTER REMODEL FROM: FOR: CONTRACTOR'S SUMMARY OF WORK Application is made for payment as shown below. Continuation Page is attached. 1. CONTRACT AMOUNT 2. SUM OF ALL CHANGE ORDERS 3. CURRENT CONTRACT AMOUNT 4. TOTAL COMPLETED AND STORED (Column G on Continuation Page) 5. RETAINAGE: a. 5.00% of Completed Work (Columns D + E on Continuation Page) b. 5.00% of Material Stored (Column F on Continuation Page) Total Retainage (Line 5a + 5b or Column I on Continuation Page) (Line 1 +1- 2) ARCHITECT: JOHNSON ARCHITECTS 440 E. CORPORATE DRIVE SUITE #102 MERIDIAN IDAHO 83642 PROJECT NAME AND LOCATION: $93,000.00 $3,987.56 $96,987.56 $96,987.56 $4,649.63 $199.75 6. TOTAL COMPLETED AND STORED LESS RETAJNAGE (Line 4 minus Line 5 Total) 7. LESS PREVIOUS PAYMENT APPUCATtONS 8. PAYMENT DUE 9. BALANCE TO COMPLETION (Line 3 minus Line 6) $4,849.38 ADDITIONS SUMMARY OF CHANGE ORDERS Total changes approved in previous months Total approved this month TOTALS NET CHANGES $3,987.56 $0.00 $3,987.56 $3,987.56 PAYMENT APPLICATION $4,849.38 $92,138.18 $88,321.37 I $3,816.81 1 DEDUCTIONS $0.00 $0.00 $0,00 Page 1 PO# 25-79 MERIDIAN SENIOR MERIDIAN SENIOR CENTER REMODEL 133 BROADWAY AVE, MERIDIAN ID 83642 APPLICATION # PERIOD THRU: PROJECT #s: 4 Distribution 10: 0811612005 P0#25-79 0 OWNER 0 ARCHITECT 0 CONTRACTOR 0 0 DATE OF CONTRACT: 04/25/2005 Contractor's signature that: (1) the Work h previously paid to..t:o materials and legally entiUl!'â f is his assurance to Owner, concerning the payment herein applied for, "~m'. " ",,'m. '" th, C,"t"" Do,"m"". (2) ,II ,"m' cto r the Contract have been used to pay Contractor's costs for labor, ~: ~ u der the Contract for WOjreViOUSIY paid for, and (3) Contractor is Þ- Date: 06/1612005 By: State of: County of: Subscribed and sworn to before me this day of Notary Public: My Commission Expires: ARCHITECT'S C ERTIFICA TION Architect's signature below is his assurance to Owner, concerning the payment herein applied for, that: (1) Architect has inspected the Work represented by this Application, (2) such Work has been completed to the extent indicated in this Application, and the quality of workmanship and materials conforms with the Contract Documents, (3) this Application for Payment accurately states the amount of Work completed and payment due therefor, and (4) Architect knows of no reason why payment should not be made. CERTIFIED AMOUNT.......................................................................................... #~B/¿' .,$} . , (ff the certified amount is cJjfferent from the payment due, you should attach an explanation. Initial all the figures thet are changed to match the certified amount.) ARCHITECT: By: Date: ø. ~1.pS- Neither this AppliCation noresnt applied for herein is assignable or negotiable. Payment shall be made only to Contracto an without prejudice to any rights of Owner or Contractor under the Contract Documents or sa. ass, INC. DOCUMENT ~t CONTINUATION PAGE Page 2 of 3 PROJECT: PO# 25-79 MERIDIAN SENIOR MERIDIAN SENIOR CENTER REMODEL APPLICATION #: DATE OF APPLICATION: PERIOD THRU: PROJECT #s: 4 08/16/2005 0811612005 P0#25-79 Payment Application containing Contractor's signature is attached, A B C D I E F G H t " COMPLETED WORK STORED TOTAL % BALANCE ITEM # WORK DESCRIPTION SCHEDULED AMOUNT AMOUNT MATERIALS COMPLETED AND COMP, TO RETAINAGE AMOUNT PREVIOUS THIS PERIOD (NOT IN D OR E) STORED (G / C) COMPLETION (If Variable) PERIODS (D+E+F) (C-G) 1. BOND FEE $2,790.00 $2,790.00 $0.00 $0.00 $2,790.00 100% $0.00 2, MOBILIZATION $1,000.00 $1,000.00 $0.00 $0.00 $1,000.00 100% $0.00 3. SUPERVISION $2,500.00 $2,500.00 $0.00 $0.00 $2,500.00 100% $0.00 4. ITEMPORARY FACILITIES $1,500.00 $1,500.00 $0.00 $0.00 $1,500.00 100% $0.00 5. EX CAVA TION-CONC RETE $8,000.00 $8,000.00 $0.00 $0.00 $8,000.00 100% $0.00 6. METAL HANDRAIL-LINTEL $7,000.00 $7,000.00 $0.00 $0.00 $7,000.00 100% $0.00 7. SAWCUTTING $400.00 $400.00 $0.00 $0.00 $400.00 100% $0.00 8. SELECTIVE DEMOLITION $4,800.00 $4,800.00 $0.00 $0.00 $4,800.00 1 OO"Æ. $0.00 9. EPOXY & REBAR $250.00 $250.00 $0.00 $0.00 $250.00 100% $0.00 10. ROUGH CARPENTRY $4,000.00 $4,000.00 $0.00 $0,00 $4,000.00 100% $0.00 11. LUMBER-MATERIALS $1,400.00 $1,400.00 $0.00 $0.00 $1,400.00 100% $0.00 12. MASONRY $800.00 $800.00 $0.00 $0.00 $800.00 100% $0.00 13. ELECTRICAL $8,400.00 $6,720.00 $1,680.00 $0.00 $8,400.00 100% $0.00 14, MECHANICAL $4,600.00 $3,680.00 $920.00 $0.00 $4,600.00 100% $0.00 15. PLUMBING $10,000.00 $10,000.00 $0.00 $0.00 $10,000.00 100% $0.00 16. FIRE SPRINKLERS $7,834.00 $7,834.00 $0.00 $0.00 $7,834.00 100% $0.00 SUB-TOTALS $65,274.00 $62,674.00 $2,600.00 $0.00 $65,274.00 100% $0.00 CONTINUATION PAGE FOR PAYMENT APPLICATION ass, INC. DOCUMENT ,~ CONTINUATION PAGE Page 3 of 3 PROJECT: PO# 25-79 MERIDIAN SENIOR MERIDIAN SENIOR CENTER REMODEL APPLICATION #: DATE OF APPLICATION: PERIOD THRU: PROJECT #5: 4 0811612005 08/16/2005 P0#25-79 Payment Application containing Contractor's signature is attached. A B C 0 1 E F G H I COMPLETED WORK STORED TOTAL % BALANCE ITEM # WORK DESCRIPTION SCHEDULED AMOUNT AMOUNT MATERIALS COMPLETED AND COMPo TO RETAINAGE AMOUNT PREVIOUS THIS PERIOD (NOT IN D OR E) STORED (G 1 C) COMPLETION (If Variable) PERIODS (0 + E + F) (C-G) 17. INSULATION $350.00 $350.00 $0.00 $0.00 $350.00 100% $0.00 18. DRYWALL $2,200.00 $2,200.00 $0.00 $0.00 $2,200.00 100% $0.00 19. PAINTING $4,610.00 $3,688.00 $922.00 $0.00 $4,610.00 100% $0.00 20. VINYL FLOORING $400.00 $400.00 $0.00 $0.00 $400.00 100% $0.00 21. CERAMIC TILE $9,957.00 $9,957.00 $0.00 $0.00 $9,957.00 100% $0.00 22. FINISH CARPENTRY $800.00 $800.00 $0.00 $0.00 $800.00 100% $0.00 23. DOORS & HARDWARE $3,007.00 $1,206.30 $300.70 $1,500.00 $3,007.00 100% $0.00 24. GLAZING $250.00 $125.00 $125.00 $0.00 $250.00 100% $0.00 25. BATH PARTITIONS $2,000.00 $400.00 $0.00 $1,600.00 $2,000.00 100% $0.00 26. BATH ACCESSORIES $1,226.00 $331.00 $0.00 $895.00 $.1,226.00 100% $0.00 27. FRP $2,576.00 $2,576.00 $0.00 $0.00 $2,576.00 100% $0.00 28, JANITORIAL $350.00 $280,00 $70.00 $0.00 $350.00 100% $0.00 29. CHANGE ORDER #1 $3,987,56 $3,987.56 $0.00 $0,00 $3,987,56 100% $0.00 TOTALS $96,987.56 $88,974.86 $4,017.70 $3,995.00 $96,987.56 100% $0.00 CONTINUATION PAGE FOR PAYMENT APPLICATION ass, INC. DOCUMENT Chapter III Financial Management ICDBG Progress Report Grantee: I :eport No.: City of Meridian, Idaho Date: Date of illOC Contract: Grant No.: August 29, 200S July 17, 2004 ICDBG-04.III-I-SR Report Period From: Report Period To: Telephone: July 21, 2005 August 29, 2005 (208) 322-7033 ext. 227 Grant Amount: Project Match Expended to Date: Tax ill No.: $100,000 $22,812 82-6000225 Second Public Hearing: (Y)/N (Circle One) Published Notice Submitted: (Y)/N Date of Second Public Hearing: June 21, 2005 Minutes Submitted: (Y)/N List of Attendees Submitted: (Y)/N PROJECT START UP <\) <\} E i;j ê;j -c "" Q Q ~ 0 <\} .... '" ]<\}"" ¡::: .g -ã .... '" -c.g ¡:¡ ~ <\} .... Q ¡::: <\} <\} ~~ ~ -g ~£'g ",p,8 ¡::: 8 ~ -§ S' S' "'U .9 o'S ~O B '" 0- '" 0 0 QS <:§Q:¡ u ~ ~ ¡iJU U ~........ Environmental Release: 08.04 06.04 0604 None Complete. Submitted 06.04 Send copy of ERR Bid Documents Reviewed and -- 03.05 04.05 None Complete Approved: Procurement for Admin Contract 01.04 02.04 03,1)4 None Complete. Part of Application Reviewed and Approved: Admin Contract Reviewed and 03.04 03.04 0304 None Complete. Part of Application Approved: Contact Person: Phone: Procurement for Eng/ Arch Contract 6.04 08.04 12.21.04 None Complete. Publication atlidavits, solicitation Reviewed and Approved: information, ranking summary, Contract Eng/Arch Contract Reviewed and 08.04 11.04 12.21.04 None Complete. Approved: Contact Person: Phone: Acquisition (voluntary or eminent If the project includes acquisition. it must be monitored. Ongoing progress domain): report schedule for acquisition activities must be established individually Date of Purchaseffransfer of Title: between grant administrator and project coordinator at IDOC Relocation (business or resident): Exhibit C 1/5 rII-13 Chapter III FAIR HOUSING PROGRESS Designate Pair Housing Resource Person: Fair Housing Review Committee: Fair Housing Resolution: Fair Housing Plan! Analysis of Impediments: Communications of Pair Housing Activities: Grantee Fair Housing Poster: SECTION 504 PROGRESS Designate Responsible Employee: 504 Committee Established: Non-Discrimination Policy Adopted: Grievance Procedure Established: 504 Self-Evaluation Completed: 504 Transition Plan: Exhibit C 2 0;1 A <::; 'd ,S: <U ~ ê¡j2 80.. -~ 8 (¡j 0 r..L1U 10/03 11/04 11/04 11/04 11/04 11/04 <U ê¡j 0 <::; 'd .g 2 <U 0;1""'" 80.. -,¡;j 8 ü¡cS 10/03 10/04 09/03 09/03 10/04 10/04 .. 09103 -- -- -- <U ê¡j 0 <::; .S: Õ ]- 0 U 10/03 -- 09/03 09/03 .. -- <U co 0 ~ ,S: OJ ~ 0 U -- -- -- 5/05 -- -- -- B 'd 2 'ê ,D ~ "'u 20 89 8.05 -- 5/05 5/05 -- -- III-14 B 'd ~ '§ ,D ~ "'u 20 89 0 ~ '" ~ '" <::; '-' <U 5'fj 8 0 ~ ..<:: .... .... u t:l.. 0 13 '" 0.. ;;::S~ None None None None None None 0 ~ '" 15 i:3 <U .... 8 ~ ~ -5d:i:î 13 '" 0.. <;S~ Yes None None None None None Financial Management 'd oJ 'd oJ oJ ~ oJ ~ <::; <::; oJ u ","5.,8 p 8 ~ oS: 0 -5 ü U Q' <t:B~ Complete. Part of Application Establish committee Rcpuhlish annually during project Develop Fair Housing Plan. Ongoing Ongoing --d <U 'd oJ oJ ~ <U ~ ~ <::; oJ <U ","5.,8 <::; 8 ~ .g 0 'S UUO" -0:;:: B ~ Will Berg-City Clerk Committee forming. Part of Application. Part of Application. Self-Evaluation underway 2/5 Chapter III Financial Management CIVIL RIGHTS PROGRESS 2 2 B '" oj "0 "0 Q Q ~ B <> '" "0 ¡:: ¡:: 'ã '5 R <> OJ ~ "0.9 .§ <> ~ ¡:: ¡:: <> <> OJ ~ ..ð ","i3..8 ~~ 2 ~ 8 0 ~ 8 p. p. "'u "5¡!:;¡::; p 8 <!.) -~ a 8 20 13 '" P. .9 0,13 '" 0 0 "'Q ~.- <!.) t}uc:r ¡I.¡U U Ci- <t.,s~ <t B ¡;; Community Profile: -- 4/05 4/15/05 None None EEO Policy Statement: "- -- 8.05 Yes None EEO Grievance ProcedureŒEO 10/03 -- S.O5 Yes None Complaints: Grantee Employment Form: -- -- -- None Complete and submit Contract/Subcontract Activity Report: -- h 8.05 Yes None Senior Center Participants Form: -- -- "" None N/A Section 3 Certifications: -- -- .. None N/A Grantee EEO Poster: -- -- .. None Ongoing ACQUISITION PROGRESS ~ <> .8 Cd "0 "0 Ci Ci § .8 <!.) '" ]<!.)~ s::: .g 'ã -C ~ "0 .9 <> ~ ¡:: <> ~ ..ð <> 100 s::: 2 ~ ~ <> 2 ~ ]8~ '" P. <!.) "'-- .~ S ~ "'U ¡:: 8 ... uP-.. 0 .9 o'S 20 E1 '" Q, '" 0 "'Q ~.- OJ 'Uuc:r ¡I.¡U U Q- <:t:.,s~ <,8 ¡;; N/A N/A N/A Nolle N/A No acquisition in this project Exhibit C 3/5 III-IS Chapter III Financial Management CONSTRUCTION AND LABOR PROGRESS 2 ~ £ '" 'd 'd Q Q .~ 0 ~ ~ '" ¡::: ¡::: ~ '" 0.> 0.> ~ 'd -S -~ E ¡:¡ ~ 0.> ~ <=1 ¡::: 0.> 0.> 0.> ~ ..ü E ~ ","i5..E ~ 0.> ~ ::; ",...... '¡:¡¿:;ã. <=1 E ~ so. 0. "'u ,- E E ~O .£:1 '" 0. ,S 0 '5 t; 0 0 "'0 ~ -- Q) õ 0 0' ¡¡¡U U 0- ..o::Bç,:: ..0:: £ ~ Contract A ward: 10.04 -- -- None Complete and submit Debarred List Checked: 10.04 3.05 4.15.05 None None Preconstruction Conference: 10.04 4.05 4.15.05 None None Minutes & Checklists Bid Tabulations: 10.04 3.05 4.15.05 None None Notice to Proceed: 10.04 4.05 4.15.05 None None Wage Rate Number: 10.04 3.05 4.15.05 None None Ten-day Wage-rate update: 10.04 3.05 4.15.05 None None Additional Classifications Required: 10.04 -- 8.05 Yes None CERTIFICA TION: I, the undersigned, do hereby certify that the above information contained in this report, including the attached payroll review and the attached disbursement report, is correct and accurately reflects the progress and status of the grant project. (208) 322-7033 ext. 227 Phone ~2(¡J~ I Date CERTIFICATION: I, the undersigned, do hereby certify that the above information contained in this report, including the attached payroll review and the attached disbursement report, is correct and accurately reflects the progress and status of the grant project. Authorized Signature for Chief Elected Official Title Date Exhibit C 4/5 III-16 DISBURSEMENT REPORT DISBURSEMENT LOG - City of Meridian Request for Funds this Period: $1,708.00 Paid to Date $97,292.00 REQUEST FOR FUNDS #6 DATE DATE DATE RECEIVED DEPOSITED DISBURSED CHECK # AMOUNT PAID TO WHOM 31-Jan-05 31-Jan-05 4-Feb-05 61406 $ 2,500.00 Sage 6-May-05 6-May-05 10-May-05 62710 $ 2,500.00 Sage 27 -Jun-05 27-Jun-05 7/11/05 63644 $ 1,000.00 Sage 27-Jun-05 27-Jun-05 6.24.05 63248 $ 16,811.58 KMO Inc. 7.8.05 7.8.05 7.11.05 63588 $ 29,896,69 KMO Inc. 8.15.05 8.15.05 8.5.05 64002 $ 41,613.10 KMO Inc. 8.15.05 8.15.05 8.5.05 64036 $ 2,000.00 Sage Idaho Community Development Btock Grant Program Request for Funds (Return to Idaho Department of Commerce, Community Development Division, 700 W. State St., PO Box 83720 Boise, ID 83720-0093) Grantee Name: City of Meridian Contract #ICDBG-04-III-l-SR Contact Person Jennifer Tomlinson Phone (20B) 322-7033 ext 22 Address: 33 E. Idaho Ave. Meridian, ID 83642 Repo rt Perio d: 7.22.0 5-8.29.05 Date of Request 8.29.05 Request #6 1 2 3 4 Total 5 6 7 8 Current ICDBG Total of Program Funds Requested + Total Funds Unexpended Balance Accrued Requests for Budget Previous Income Earned Program Income Disbursed of Funds Req. + (unpaid) Bills & Funds Col A. Administration $ 10,000 $ 9,000 $ - $ 9,000 $ 9,000 $ 1,000 B. Architectural $ - $ - $ - $ - $ - C. Construction: Materials & Fencing $ 90,000 $ 88,292 $ - $ 88,292 $ 88,292 $ 1,708 $ 1,708 $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - E. legal $ - $ - $ - $ - $ - $ - F. Audit $ - $ - $ - $ - $ - $ - TOTALS $ 100,000 $ 97,292 $ - $ 97,292 $ 97,292 $ 2,708 $ - $ 1,708 * This category includes SCADA software but no other accessories nor installation of equipment. Note: Furnishing false information may constitute a violation of applicable state and federal law. Certification of Financial Officer: I certify that the above data is correct, based on the grantee's official accounting system and records, consistently applied and maintained, and that expenditures shown have been made for the purposes of, and in accordance with applicable contract terms and conditions. The funds requested are for reimbursement of actual expenditures during the report period. Signature Typed Name Title ReqF unds- 5 - Me ridS e nio rs E-< U') a u ~ u ~ ~ ~ 0 ~ < ¡:l., :lUIOd ~ ~ < ~ ' z ' ;¡m¡UujJ1S pnl1oq¡ny Z I I I I I I I I I I I I I I I I I I SM.;¡1Al;¡¡UI [~"Cw I , I , I I I I I I I I I I I , I I I I I SM.;¡1Al;¡¡U¡ ;¡11SUO I I I I , I I P;¡¡;¡IdlUo;J I I I I I I I I , I I I I I SM.;¡1Al;¡¡U¡ 'oN I I I I I I I SlUIOd d¡qS;¡J!1U;¡lddy ~ I < < < < < p;¡l¡nb;¡~ I --- Z Z Z Z I Z Z I Z Z Z Z Z S;¡::Jpu;uddy I , ~ I Z I I Z ' suopu::JmssuI;J mds I I I I I I I I Z I Z I I Z I I I I , P;¡~FO M. ;¡lUPl;¡AO I I I I >- >- >- >- I >- I qSU;J U1 PfCd ;¡jJUl1d ' I I , ¿;Jom < Z < ~ I ~ I Z Z I I O¡ ¡U;¡S mId 'SJÃ)I I I Z >- Z Z I Z I ¿mId O¡ PfCd ;¡jJUl1d I I I I soof)"C::J1)1ss"C{;) M I M I , M I I I I I ){1OM.)0 'oN I I I I S;¡;¡,(°IdlU3)0 'ON "T I 0 I M I I ('I'") I I I I I JHd 00 SnOlÃ"Cd)O 'oN 0 0 "T 0 0 M 0 - ;JOm O¡ ¡U;¡S so°!1"C::J1)pl;¡;J >- Z Z Z Z Z Z PUljU°;J!P1U¡UOJqns JI!d uo SUopU::Jmjl;¡;J >- Z >- Z Z Z Z P"CljU°;Jn::JUl)uoJqns ~ .~ OJ) ~ ...... ¡:: .~ .~ u g """; æ () ...... æ u ~ ..... .... u (I) .§ ¡:: ..s:: ~ 0 ,..s::: ¡:;:: .,....; u ~~ ¡:;:: u 0 § ~ 0 () (I) (I) ...., () U ......'.;::1 ~ () .81;/ ~ U (I) U u ....c:: ~ § 0 ~ () () (I)"""; g ~ ~ - p:¡...... (I) i:: d U U p:¡ () e ~ ooD :s () Ua ~ < U') Q¡:l., p:¡U') ~ 1. Grantee Name City of Meridian I 3. Grant No. ICDBG 04-111-1-SR 2. Contact Person Marianne Piquet Phone (208) 322-7033 ex!. 215 4. Report Period Interim 04/14/2005 Final Date of Report 5. Contractor/Subcontractor Name and Address Name Street City State Zip 6. Contractor/Subcontractor 7. Amount of 8. Type of 9. Business Code IRS Number contract trade Race/Gender (1 tbru 3) Code (1 thru 6) KMOJ Inc. 923 16th Ave. S., Ste. A Nampa 10 83651 82-050195 $ 93,000,00 3 1 RM Mechanical, Inc. P. 0, Box 45429 Boise ID 83711 82-0376073 $ 3 1 ACE Construction Company p, O. Box 406 Boise 10 83709 82-0516908 $ 7,604,00 3 1 SBI Contracting, Inc. 228 E. Plaza, #193 Eagle 10 83616 46-0473188 $ 5,095.00 3 1 DeBest Fire Protection, Inc. 11477 W. President Dr. Boise ID 83713 82-0498987 $ 6,995.00 3 1 Buss Mechanical Services, Inc. P. O. Box 190476 Boise ID 83719 3 1 Idaho Community Development Block Grant Program ACTIVITY REPORT Contract/S u bcontracts TRADE CODE: I-Professional Services 2-S upplieslEquipment 3-Construction RACE/GENDER CODE: I-White 2-Black 3-American Indian 4-Hispanic 5-Asian/Pacific Islander 6-Women Business Enterprise I:\WORK\PLANNING\\CDBG\FORMS"-Admin Frms Current\Bid Doc Inserts & Labor\Labor Docs\ContractActivityReport.doc (T Q.. (T (T a 0) to V CD CD a N u a.. (/ f- U LLJ f- ..... J: U ~ a: z: a (/ z: J: a ...., 11 C\! C\! ..... ..... lJJ g- O) t\J ~"" :J a: PAYMENT APPLICATION TO: CITY OF MERIDIAN 33 E. IDAHO AVENUE MERIDIAN IDAHO 83542 WIL BERG KMO INC 923 16TH AVENUE SOUTH ,SUITE-A NAMPA IDAHO 83651 MERIDIAN SENIOR CENTER REMODEL FROM: FOR; CONTRACTOR'S SUMMARY OF WORK Application is made for payment as shown below. Col'ltinuation Page is attached. 1. CONTRACT AMOUNT 2. SUM OF ALL CHANGE ORDERS 3. CURRENT CONTRACT AMOUNT 4. TOTAL COMPLETED AND STORED (Column G on Continuation Page) 5. RETAI NAG E: a. 5,00% of Completed Work (Columns D + E on Continuation Page) b, 5.00% of Material Stored (Column F on Continuation Page) Total Retainage (Une 5a + 5b or Column I on Continuation Page) (Une 1 +/- 2) Page 1 PROJECT PO# 25-79 MERIDIAN SENIOR NAME AND MERIDIAN :SENIOR CENTER REMODEL LOCATION: 133 BROADWAY AVE, MERIDIAN ID 83642 APPLICATION # PERiOD THRU: PROJECT #s: DATE OF CONTRACT: 4 Distribution to: 0811612005 0 OWNER PO#25-79 0 ARCHITECT 04/2512005 0 CONTRACTOR 0 0 ARCHITECT: JOHNSON ARCHJTECTS 440 E. CORPORATE DRNE SUITE #102 MERIDIAN IDAHO 83642 $93,000.00 $3,987,56 $96,987,56 $96,987.56 $4,649.63 $199,75 6. TOTAL COMPLETED AND STORED LESS RETAINAGE (Line 4 minus Line 5 Total) 7, LESS PREVIOUS PAYMENT APPUCATIONS $4,849.38 $92,138.18 $88,321.37 8. PAYMENT DUE 9. BAlANCE TO COMPLETION (line 3 minus Une 6) I C $3,816.81 I ~~ $4,849.38 .~ r SUMMARY OF CHANGE ORDERS Total changes approved in previous mor¡ths Total approved this month TOTALS NET CHANGES PAYMENT APPLICATION ADDmONS $3,987.56 $0.00 $3,987.56 $3,987.56 DEDUCTIOÑS $0.00 $0.00 $0.00 By: Contractor's signature that (1) tile Work previously paid to. materials arid legally ant" is his assurance \0 Owner, concerning tile payment herein applied for, rformed as required in the Contract Documents, (2) all slims !r the Contract have been used to pay Contractor's costs for labor, S ul\der the Contract for Work previously paid for, and (3) Contractor is t. I ¿f Þ-- Date: o.aå6i2oos... " - ~' . ,' !', , .-. ',1, ", ',I,:, "- 'I / ") -', : , ! I}" ,.; , " , " State of: County of: 4.6 /'(/ ~ ~ ",_,1 Subscribed and swam to before me this day of "..'; .. Notary pubnc: My Commission Expires: ARCHITEcrs CERTIFICATION Archftect's signature below is his aSSUrance to OWner, concerning the payment herein applied for, that: (1) Architect has inspected the Work represented by this Application, (2) such Work hæ been completed to the extent tndicated in this Application, and the quality of workmanship and materials conforms wîth the Contract Documents, (3) this Application for Payment accurat~ states the amount of Work completed and payment due therefor, and (4) Architect knows of no reason why payment should not be made. IJ" CERTIFIED ..MOUNL..".....""".."......"..".....-..""."....,....". ""........., .."......... ~. B / t:. "" I? . Ç!. (If the certffied amount is different from the payment due, you should attach an expl lion. " " Initial ell the figures that are c1Jånged to match /he certffied amouno-'-g- ARCHITECT: /J~ >~ .. ----. -..I.. /7 t?1 -,c 'C)- By: Date: .- V I ~ 'j. r payment applied For herein is assignable or negotiable. Payment shall' C ~nd is without prejudice to àny ñghts of Owner or Contractor under ise. ass, INC. DOCUMENT 'it c.... C'ì (TJ 0 0') to 'it aI aI 0 C\I u a- U) f- U W f- H I U C! CI: z: 0 en z: I 0 r¡ (I N N ..... ..... IJ) 0 ~ 0') N b.O~ :J CI: CONTINUATION PAGE Page 2 of 3 PROJECT: PO# 25-79 MERIDIAN SENIOR MERIDIAN SENIOR CENTER REMODEL APPUCATION #: DATE OF APPLICATION: PERIOD THRU: PROJECT tis: 4 08116/2005 0811612005 P0#25-79 Paymerrt Application containing Contractor's signabJre ls attached. A B C D E F G H I COMPLETED WORK STORED TOTAl % BALANCE ITEM # WORK DESCRIPT!ON SCHEDULED AMOUNT AMOUNT MATERIALS COMPLETED AND CaMP, TO RETAiNAGE AMOUNT PREVIOUS THIS PERIOD (NOT IN D OR E) STORED (G IC) COMPLETION (If Variable) PERIODS (0 + E + F) (c..G) 1. BOND FEE $2,790.00 $2,790.00 $0.00 $0.00 $2,790.00 100% $0.00 2. MOBIUZATION $1,000.00 $1,000.00 $0.00 $0.00 $1,OOO,DO 100% SO..oo 3. SUPERVISION $2,500.00 $2,500.00 $0.00 $0.00 $2,500.00 100% SD.OO 4. TEMPORARY FACILITIES $1,500.00 $1,500.00 $0.00 SO.OO $1,500,00 100% $0.00 5. EXCAVATION-CONCRETE S8,OOO.DO S8,DDD.OD SO. 00 $0.00 sa,OOO.DO 100% $0.00 6. METAL HANDRAIL-LINTEL S7,000.00 $7,000.00 SO,OO SO.OO $7,DOO.00 100% $0.00 7, SAWCUTTING $400,00 $400.00 SO.OO SO.OO $400 .00 100% SO.OO 8. SELECTIVE DEMOlmON $4,800.00 $4,800.00 50.00 $0.00 $4,800.00 10D% $0.00 9. EPOXY & REBAR $250.00 S25D.00 $0.00 $0.00 $250.00 '00% $0.00 10. ROUGH CARPENTRY $4,000.00 $4,000.00 $0.00 50.00 $4,000.00 100% SO.OO 11. l UMB E R -MATERIALS $1,400.00 51,400.00 $0.00 $0.00 $1,400.00 100% $0.00 12. ¡MASONRY $BOO. 00 $800.00 $0.00 $0.00 $800.00 100% $0.00 13. ELECTRICAL $8,400,00 $6,720.00 $1,680.00 $0.00 $8.400.00 100% 50.00 14. MECHANICAL $4,600.00 $3,680.00 $920.00 $0.00 $4,600.00 100% $0.00 15. PLUMBING $10,000.00 $10,000,00 $0.00 $O.DO $10,000.00 100% $0.00 16. FIRE SPRINKlERS $7,834.00 $7,834.00 $0.00 $0.00 $7,834.00 10D% $0.00 SUB-TOTALS $65,274.00 $62,674.00 $2,600.00 $0.00 $65,274.00 100% $0.00 CONTINUATION PAGE FOR PAYMENT APPLICATION QSS, INC. DOCUMENT In Q... ('T) ('T) 0 Ol lD V m m 0 N u a.. (f) f- U lJJ f- H :J: U æ a: z: 0 en z: :J: 0 t¡ rr¡ N N .... .... In 0 . . OJ N '-C1. :J .a::: CONTINUATION PAGE Page30f 3 APPLICATION #: DATE OF APPLICATION: PERIOD THRU: PROJECT #5: 4 08/1612005 0811612005 P0#25-79 PROJECT: PQ# 25-79 MERIDIAN SENIOR MERIDIAN SENIOR CENTER REMODEL Payment Application containing Contractors signature is attached. A B C D E F G H I COMPLETED WORK STORED TOTAL % BALANCE f1EM # WORK DESCRIPTION SCHEDULED AMOUNT AMOUNT MATERIALS COMPLETED AND COMPo TO RETAINAGE AMOUNT PREVIOUS THIS PERIOD (NOT IN D OR E) STORED (G I C) COMPLETION (If Variab~) PERIODS (D+E+F) (C-G) 17. INSULATION $350.00 $350.00 $0.00 $0.00 $350.00 100% $0.00 16. DRYWALL $2,200.00 $2,200.00 $0.00 $0.00 $2,200,00 100% $0.00 19. PAINTING $4,610.00 $3,686.00 $922.00 $0.00 $4,610,0{) 100% $0,00 20. rvJNYL FLOORING $400.00 $400.00 $0.1)0 $0.00 $400.00 100% $0.00 21. CERAMIC TILE $9,957.00 $9,957,00 $0.00 $0.00 $9,957.00 100% $0.00 22. IFINISH CARPENTRY $600.00 $800,00 $0.00 $0.00 $800.00 100% ${LOo 23. ¡OOORS 8; HARDWARE $3,007,00 $1,206.30 $300.70 $1,SOO.00 $3,007.00 100% $0.00 24. GlAZING $250.00 $125.00 $125.00 $0.00 $250.00 100% SO.OO 25. BATH PARTITIONS $2,000.00 $400.00 $0.00 $1,600.00 $2,000.00 100% $0.00 26. BATH ACCESSORIES $1,226.00 $331.00 SO.OO $895.00 $1,226.00 100% $0.00 27. FR? $2,576.00 $2,576.00 $0.00 $0.00 $2,576.00 100% $0.00 28, JANITORIAL $350.00 $280.00 $70.00 $0.00 $350.00 100% $0.00 29. CHANGE ORDER #1 $3,987.56 iì3,961.56 $0.00 $0.00 $3,987.56 100% $0.00 TOTALS $96,987.56 $88,974.66 $4,017.10 $3,995.00 $96,967.56 100% $0.00 CONTINUATION PAGE FOR PAYMENT APPLICATION ass, INC. DOCUMENT ~ , It. (T) (T) 0 (1 (! '\I" CD CD 0 C\I u c.. UJ I- U lLJ I- ..... .J: u æ a: z: 0 UJ z: ::r: 0 ,.., II (T) C\I ..... ..... If) 0 . (1 N lO. ::J a: PAYMENT APPLICATION CITY OF MERJDIAN 33 E. IDAHO AVENUE MERID1AN IDAHO 83642 WIL BERG FROM: KMO 1NC 923 16TH AVENUE SOUTH. SUITE-A NAMPA IDAHO 83651 MERIDIAN SENIOR CENTER REMODEL TO: FOR: CONTRACTOR'S SUMMARY OF WORK Application is made for payment as shoWl'1 balow. Continuation Page is attached. 1. CONTRACT AMOUNT 2. SUM OF ALL CHAPIGE ORDERS 3. CURRENT CONTRACT AMOUNT 4. TOTALCOMP~ßANDSTORED (Column G on Continuation Page) (line 1 +/. 2) 5. RETAlNAGE: a. 0.00% of Completed Work (Columns 0 + E on Continuation Page) b. (tOO% of Material Stored (Column F on Continuation Page) Total Retainage (Line 5a + 5b or Column J on Continuation Page) 6. TOTAL COMPlETED AND STORED LESS RETAINAGE (line 4 minus Une 5 Tataf) 7. lESS PREVIOUS PAYMENT APPLICATIONS Page 1 ~;~ ~:- -':. O. tñbution to: .;~.- :cN'.5..... IS 0811612005 0 OWNER P0#2S-79 0 ARCHITECT <W25I2005 0 CONTRACT' 0 D PRDJECT POI 25-79 MERiDIAN SENIOR NAME AND MERIDIAN SENIOR CENTER REMODEL LOCATION: 133 BROADWAY AVE, MERIDIAN ID 83642 APPUCAn:~. PERIOD THRU:. PROJECT #5: DATE OF CONTRACT: ARCHITECT: JOHNSON ARCHITECTS 440 E. CORPORATE DRIVE SUITE #102 MERIDIAN IDAHO 83642 $93,000.00 $3,987,56 $96,987.56 $95,987.56 $0.00 $0,00 Contractors' that (1) th§"ll\/o previo m~n legallyenti re biW Is his assurance 10 Owner, concerning the payment here.in applied for, as bee performed as required in the Contract Documents, (2) all sums ontract r under tt\e Contract have been used to pay Contractor's costs for labor, obI' under the Contract for Wo¥previously paid for, and (3) Contractor Is !sp- - - By: Date: .08/1~0~ : I ' '. '; ~ ,', ' State of: County of: Subscribed and swom to before / " : -, .'. '. , ,'. me thís day of Notary Public: My Commission Expires: ~ I ARCH ITECT'S CERTIFICATION $95,987.56 Architect's signature below Is his assurance to Owner, concerning the payment herein applied for, that: (1) Ard1itect has Inspected the Work represented by this Application, (2) such WoñI. has been completed to the extent irn:licated in this Application, and the quality of workmanship and ma!eñals ""[111:"" . "::':~1'~¿~;:~;:: ~~y~:: ~:':h~;~: ~:"~\:iÄ~~:;¡:i:~"; =:=~::y"p;~~~ ,'"0' CERTIFIED AMOUNT...................._........_.....................................,................... 8. PAYMENT DUE 9. BALANCE TO COMPLETION (Line 3 minus LIne 6) SUMMARY OF CHANGE ORDERS . Total changes approved il1 previous months Total approved this month TOTALS NET CHANGES PAYMENT APPLICATION ADDITIONS $3,987.56 $0.00 $3,987.56 $3,987.56 $0.00 DEDUCTIONS $0.00 $0.00 $0.00 (If the cerlifíed amount is different from the payment due, you should aitach an explanatíon. Initial all the figures that are changed 10 match the certified amount) ARCHITECT WALTER UNGREN ~: D~; Neither !his AppNcation nor payment applied for herein is assigrnlble or negotiable. Payment shall be made only to Contractor, and is without prejudice to any rights of Owner or Contrador under the Contract Documents or otherwise. ass, INC. DOCUMENT r-- Q.. cry cry a en w "f- CD CD a C\J t.:) a.. (I) l- t.:) l.1J I- H I t.:) a::: a: z: a (I) z: I a "'1 n¡ cry C\J .... ..... IJ') 0 en N U. :J a: CONTINUATION PAGE Page 2 of 3 APPlICATION #: DATE OF APPLICATION: PERIOD THRU: PROJECT fI.s: 5 C8f1612005 08116/2005 PD#25- 79 PROJECT: PQ# 25-79 MERIDIAN SENIOR MERIDIAN SENIOR CENTER REMODEL Payment Application corrtalning Contractors signature is attached, A B C 0 E F G H I COMPlETED WORK STORED TOTAL % BAlANCE ITEM # WORK DESCRIPTION SCHEDULED AMOUNT AMOUNT MATERIALS COMPLETED AND COMP, TO RETAtNAGE AMOUNT PREVIOUS THIS PERIOD (NOT IN 0 OR E) STORED (G IC) COMPLETION (If Variable) PERIODS (D+E+F) (CoG) 1. BOND FEE $2,790.00 $2,790.00 SO. DO $0.00 $2,790.00 100% $0,00 2, MOBIUZATION $1,000.00 $1,{JOD.00 $0.00 $0.00 $1,000.00 100% $0.00 3, SUPERVISION $2,500.00 $2,500.00 $0.00 SO.OO $2,500.00 10D"Æ. $0.00 4. TEMPORARY FACILITIES $1,500.00 $1.500,00 $0.00 SO.OO $1,500.00 100% $0.00 5. !ExCAVATlON-CONCRETE $8,000.00 $8.000.00 $0.00 $0.00 $8,000.00 100% $0.00 6. METAL HANDRAIL-LINTEL $7,000.00 $7,000.00 $0,00 $0.00 $7,000.00 100% $0.00 7. SAWCUTTING $400.00 $400.00 $0,00 $C.OO $400.00 100% $0.00 8. SELECTNE DEMOlITION $4,800.00 S4,8OD.00 $0.00 $0.00 $4,800.00 100% $0.00 9. EPOXY & REBAR $250.00 $250.00 $0.00 $0.00 $25{.00 100% $0.00 10. ROUGH CARPENTRY $4,000,00 $4,000.00 $0.00 $0.00 $4.000.00 100% $0.00 11. LUMBER-MATERIAlS $1,400.00 $1ACMO $0.00 SO.DO $1,400.00 100% $0.00 12. MASONRY $800.00 $800.00 $0,00 $0.00 $800.00 100% $0.00 13. ELECTRICAL $8,400.00 $8,400.00 $0.00 SO.DO $8,400.00 100% $0.00 14. MECHAN!CAL $4,600,00 $4,600.00 SO.CD $0.00 $4,600.00 100% SO.OO 15. PLUMBING $10,000.00 $10,000.00 $0.00 $0.00 S10,000.00 100% $0.00 16. !FIRE SPRINKLERS $7,834.00 $7,834,00 $0.00 $0.00 $7,834.00 100% $0,00 SUB-TOTALS $65,274.00 $65,274.00 SO.OO $0.00 $65,274.00 100% $0.00 CONTINUATION PAGE FOR PAYMENT APPlICATION ass, INC. DOCUMENT Aug 29 05 11:23<3 < , ..-' JOHNSON ARCHITECTS PC 208 846 9033 10.8 ~¡: --,'J.,' -,;..,"~~~;~, C-":{1 6ridí{r!1 ,:. '\ \~ - " '-" - ,_,_r":'~"'X """""'-.=';--""""~"I~" CITY OF MERIDIAN CERTIFICATE OF OCCUPANCY Pc,rmlt "# BP2005-6-17 9/512005 ApplicQnt: Mer\didr'i Set",IQ~ Citizens Cl!mter Parcel Number: PARC2001.1529 Contr1íctor: 70 St:. DË"1"E~MINEO '" K¡ÍfO ~ÔJ1str(jci!oru C¡fpl-,;( (Pi? i Address: 133 Broadway Ave. 'IN. Subdivision: Lot(s) Block ÞrojDe$~ : Pt.lrpo~e~ SbuctUse: JobYalue: \1~Hii;'¡;ßn S'¿r1ior Oti::éf'\.$ C011t!i\t T enant!mprúvemeont C::o.mmercLai $90,000.00 LivingSpace: Bernt/Star; Garage: Structure Area: 5,495.00 0 CCUP ANCY REQUIREMENTS APPLI-?~~.APPROVALS ~~ '[)',- 1 ~ ,~ ~/ Building Department r:./~ Certificates of occupancy must be posted in a conspicuous place when the occupancy of the structure is other than residential. IVy ¡VIA Planning and Zoning .. Deviation from the approved occupancy for which this certificate has been issued is unlawful. The issuance of a Certificate of Occupancy shall not be construed as an approval of a violation of the provisions of the Meridian City Building and Fire Codes or of other ordinances of this jurisdiction. ~gin..ring D .par~nt ~ ~ /~. tP,/~ Fire Department AlaS.Hevls.d 512 1/0J