Form ID

Publication date

Location of premises

Certificate

Date substantially performed:
Date certificate signed:

Participants

Name of Owner
Corporation of the City of Brockville
Address of Owner
Victoria Building, 1 King Street West, P.O. Box 5000, Brockville, ON K6V 7A5
Name of Contractor
Ken Miller Excavating Ltd.
Address of Contractor
2148 2nd Concession, Maitland, ON K0E 1P0
Name of Certifier
S.E. Allen, C.E.T. Supervisor of Engineering
Address of Certifier
Same as Owner

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

Owner