Form ID

Publication date

Location of premises

Certificate

Date substantially performed:
Date certificate signed:

Participants

Name of Owner
Oxford County
Address of Owner
21 Reeve Street, P.O. Box 1614, Woodstock, ON N4S 7Y3
Name of Contractor
Permanent Paving Limited
Address of Contractor
P.O. Box 1707, Woodstock, ON N4S 0B1
Name of Certifier
Melissa Abercrombie, P. Eng.
Address of Certifier
Same as Owner

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

as above