Form ID

Publication date

Location of premises

Certificate

Replacement of Roof Sections 101 and 201 as per Fishburn Specification dated August 2006

Date substantially performed:
Date certificate signed:

Participants

Name of Owner
Grand Erie D.S.B.
Address of Owner
349 Erie Avenue, Brantford, ON
Name of Contractor
SempleGooder Roofing Limited
Address of Contractor
1365 Martin Grove Rd., Rexdale, ON
Name of Certifier
Fishburn Building Sciences Group Inc.
Address of Certifier
15391 Steeles Avenue, Hornby, ON

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

Address