Form ID

Publication date

Location of premises

Certificate

Project No. WSR-438-08 Grade & Utility Construction

Date substantially performed:
Date certificate signed:

Participants

Name of Owner
Corporation of the Town of Kirkland Lake
Address of Owner
#1 Dunfield Road, Postal Bag 1757, Kirkland Lake, ON P2N 3P4
Name of Contractor
Pedersen Construction Inc.
Address of Contractor
Hwy 11 & 66 West, PO Box 2409, New Liskeard, ON P0J 1P0
Name of Certifier
Owner
Address of Certifier
same as above

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

Owner's Address