Form ID

Publication date

Location of premises

Certificate

Asphalt Paving & Concrete Work #03-T15

Date substantially performed:
Date certificate signed:

Participants

Name of Owner
City of Cornwall
Address of Owner
1225 Ontario St., Cornwall, ON
Name of Contractor
Cornwall Gravel Co. Ltd.
Address of Contractor
390 11th Street West, Cornwall, ON
Name of Certifier
Jean Lemire
Address of Certifier
as above

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

City of Cornwall.