Form ID

Publication date

Location of premises

Certificate

Oxford Road 46 - Culvert Replacement, Contract 930200-B-2010

Date substantially performed:
Date certificate signed:

Participants

Name of Owner
County of Oxford
Address of Owner
21 Reeve Street, P.O. Box 1614, Woodstock, ON N4S 7Y3
Name of Contractor
Theo Vandenberk Construction Inc.
Address of Contractor
15673 Fifteen Mile Road, RR 2, Denfield, ON N0M 1P0
Name of Certifier
Dadean Assam, P. Eng.
Address of Certifier
Same as owner

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

as above