Form ID

Publication date

Location of premises

Certificate

Site Servicing

Date substantially performed:
Date certificate signed:

Participants

Name of Owner
City of London
Address of Owner
PO Box 5035,
Name of Contractor
Monte Vista Contracting
Address of Contractor
9361 Oriole Drive, Mount Brydges, Ont. N0L 1W0
Name of Certifier
Development Engineering (London) Limited
Address of Certifier
361 Dufferin Avenue, London, ON N6B 1Z5

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

Addresses as above