Form ID

Publication date

Location of premises

Certificate

Project No. WSR-410-02, Grade & Utility Construction Premier Avenue West (Earl to Queen)

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
P.O. Box 2409, Hwy. 11 & 65 W., 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

Owners address