Form ID

Publication date

Location of premises

Certificate

Intermediate Coat Feather Duster CAMI PO# 470044

Date substantially performed:
Date certificate signed:

Participants

Name of Owner
Autotac Inc.
Address of Owner
1235 Chicago Rd., Troy, Michigan, USA 48083
Name of Contractor
same as above
Address of Contractor
same as above
Name of Certifier
Janet L. Beam, Autotac Inc.
Address of Certifier
1235 Chicago Rd., Troy, Michigan, USA 48083

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

Autotac Inc., 1235 Chicago Rd., Troy, Michigan, USA 48083