Form ID

Publication date

Location of premises

Certificate

Project No. WSR-388-99, Grade & Utility Construction.

Date substantially performed:
Date certificate signed:

Participants

Name of Owner
Corporation of the Town of Kirkland Lake.
Address of Owner
#1 Dunfield Rd., Postal Bag 1757, Kirkland Lake, ON P2N 3P4.
Name of Contractor
Pedersen Construction Inc.
Address of Contractor
P.O. Box 2409, Hwy 11 & 65 West, New Liskeard, Ont. P0J
Name of Certifier
Owner.
Address of Certifier
Same as above.

Office to which claim for lien must be given to preserve lien

Owner's address.