Form ID

Publication date

Location of premises

Certificate

Placement of HL-3 asphalt

Date substantially performed:
Date certificate signed:

Participants

Name of Owner
Middleburg Developments c/o
Address of Owner
23 Lesmill Road, Suite 111, Toronto, ON M3B 3P6
Name of Contractor
Hollingworth Construction Co.
Address of Contractor
41 Cardico Drive, Box 424, Gormley, ON L0H 1G0
Name of Certifier
Sabourin Kimble & Associates Ltd.
Address of Certifier
110 Old Kingston Road, Pickering Village, Ajax, ON L1T 2Z9

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

19T (W) 99002