Form ID

Publication date

Location of premises

Certificate

Roof Repairs

Date substantially performed:
Date certificate signed:

Participants

Name of Owner
Her Majesty the Queen in right of Ontario as represented by the Chair of the Management Board of Cabinet
Address of Owner
Project Manager, Tempest Management Corp., 304 The East Mall
Name of Contractor
Keller Roofing & Sheet Metal Inc.
Address of Contractor
206 Victoria St. W., Exeter, ON N0M 1S2
Name of Certifier
Mr. Howard Crummer
Address of Certifier
900 Highbury Ave, PO Box 5452, London, ON

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

The Chief Executive Officer, Ontario Realty Corporation, 11th Floor, Ferguson Block, Queens Park, Toronto, ON M7A 1N3