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2007-2-23 Receipt and Waiver of Mechanics Lien Rights/ Withholding Affidavit for Contractors P.O. Box 256 � Phone (763) 497-2428 5050 Barthel Industrial Dr. � Fax (763) 497-3893 I � � �� Albertville, MN 55301 �.� �� www.dennisfehn.com � �'�vEL - EXCAVAT1�G nvC. DATE ��--�- RECEIPT AND WAIVER OF MECHANIC'S LIEN RIGHTS The undersigned hereby acknowledges receipt of the sum of: $-----�--��-�'-��------from Dennis Fehn Gravel & Excavating,Inc. 1)---------------partial payment for labor,skill and material furnished 2)---X--------as payment for all labor,skill and material furnished or to be furnished (except the sum of---3�`��-`t-=��-retainage or holdback) 3)----------------as full and final payment for all labor,skill and material furnished or to be furnished to the following described real property: (project name) ��c�.�V �-t � �:...v� and for the value received hereby waives all rights acquired be the undersigned to file or record mechanic's liens against said real property for all labor,skill or materials furnished to said real property(only for the amount paid if No 1 is checked and except for the retainage shown in Box 2 is checked). The undersigned affirms that all material furnished by the undersigned have been paid for, and all subcontractors employed by the undersigned have been paid for, and all subcontractors employed by the undersigned have been paid in full, EXCEPT(please insert none if no obligation is owing): NOTE: If this instrument is executed by a corporation,it must be si�ned by an officer,if executed by a partnership,it must be signed by a partner and if executed by a sole proprietor,it must be signed by the sole proprietor. � y ` �� -------�-Y Y� --- -------- ------------ � By:- - - - - -- -- Title:--�1�' -��=s'-�'�-�------------ Address:--�l--�-�-=�-�--�J---��1_�'_�_�f'�� j��/zGc�� /�,l"1 �ro�� COMMERCIAL & RESIDEN�'IAL SITEWORK+ ROADBUILDING SAND & GRAVEL• DECORATIVE MATERIALS EQUAL OPPORTUNITY EMPL�YER P.O. Box 256 � Phone (763) 497-2428 5050 Barthel Industrial Dr. � FaY (763) 497-3893 � � Albertville, MN 55301 �� www.dennisfehn.com � G�VEL - EXCAVATIN�` �NC. DATE -��Q� RECEIPT AND WAIVER OF MECHANIC'S LIEN RIGHTS The undersigned hereby acknowledges receipt of the sum of: $----�-t�--��=-��----------from Dennis Fehn Gravel & Excavating,Inc. 1)---------------partial payment for labor,skill and material furnished 2)------X-------as payment for all labor,skill and material furnished or to be furnished I (except the sum of�-"t�5--��----retainage or holdback) 3)----------------as full and final payment for all labor,skill and material furnished or to be furnished to the following described real property: (project name) �r a_:..��Z, �� and for the value received hereby waives all rights acquired be the undersigned to file or record mechanic's liens against said real property for all labor,skill or materials furnished to said real property(only for the amount paid if No 1 is checked and except for the retainage shown in Box 2 is checked). The undersigned affirms that all material furnished by the undersigned have been paid for, and all subcontractors employed by the undersigned have been paid for, and all subcontractors employed by the undersigned have been paid in full, EXCEPT(please insert none if no obligation is owing): 1�T(,1TF� Tf thic inctpirpPnt ic exPr>>tP�l hy a C�rpnr�Yion;ll T11USt he 51�11eC�bV 311 Of�CeI'.lf executed by a partnership,it must be signed by a partner and if executed by a sole proprietor,it must be signed by the sole proprietor. �e��i�__�(�,;:v S �n(�. ------------ -i----------- By:------- --- ----------------------- {�,.�s;d�..� Title:------------- ----------------------- 19740 KENRICK AVENUE Address:------------------------------------ LAKEVILLE,MN 55044 COMMERCIAL & RESIDENTIAL SITEWORK� ROADBUILDING SAND & GRAVEL• DECORATIVE MATERIALS EQUAL OPPORTUNITY EMPLOYER f�001/IvI�;R/06/TUE 10: 09 AIVI PJOPTHDALE CONST. FAY No, 7634284997 P, 001/001 i■ � f■ ■ P.O. Eox 256 ��" Phone (763) 497-2428 I 5050 Bazthel Industrial Dr. N � F2� (763) 497-3893 � � E�� A]bertville, MN 55301 � www.dennisfehx�.com � �'�AvEL - EXCAv�Ti�G � nvc. DA`rE -��a3�-�-�-_7_ RECETPT AND �V"A.�VER OF MEC��ANIC'S LIEN RICr�TTS The undezsigned hereby ac�ovvledges recezpt of the sum of: ! �___�_�`-�—��-_��---from Dennis Fehu Crravel &Excavating,Inc. � 1)--------------partial payment for laboz,skill and matez�al�urnished � � . _ ,. 2)-----�-----�as payment for all labor;skill`an,d zxxatezial furnished oz to be fiur�ished . (exce�t the sum of--�"�-`>-�3�-�-��retainage oz�aoldback) ' 3,----------------as full and final payment for all labox,skill and material �uxx�ished or to -------•----�- --,._.�....._..._... _.,,.--....__._..._..... .........._.,_. ,._..... . ...,.. .:.. .. . . ._�_._._..,_...._._�._._ ...._., be furnis�aed to the followixig deacribed�real propezty:��- roject riariie�"-�'--� � � . , � «. ��-:•.��•_.,__...._,...___--�-----------------�--.....--- �r o�� ,r- _ . . _, azxd�or the value zeceived hereby waives all rights acquired be the uz�.dezsigraed to file or zecord mechaz�ac's liens against said real property�or all labor,skill oz zi�aterials fuinished to said real pzoperty(only foz the amount paid if No 1 is checked and exceQt for the retainage shown in Box 2 is checked). Tk�e undersigned a£fzzzz�.s tha�all material �. I fia.zrusb�ed by the un.dezsi.gned have beez�paid for, and a�l subcontractors employed by the i undersigned have been�aid for, axld all subcontractors employed by the wadersigned �ave been paid in full,EXCEPT(please insert zzoz�e if no obligatiozz zs ovving):` NOTB: If this insti-�uxzex�t zs executed by a eor�poration,it rr�ust be signed by an officer,i� . e�ecuted by a pax�bnership,it must be signed by a part�er and if executed by a sole propzietor,it must be signed by the sole�roprietor. _��'��--��`j=�u�� , . - . ..� � �� _ , . . _ . . . By : � � ` � - - ;Tztle: --U----�-�-�-`'--'��e-�-�.._----------- , i , - . _ . � _ � . - _ - . � �� rf+�i � � o � .� i Address:-��-�-------------------- ,.._ . _ . .. _ _ ... . . .. . ... . . . .. _. .._ ....--�- - -- . .. .._ _ ...__ . _ , / . __ .. .... .. . � . . , . . . ,�y� -� �s�3��_, CO�VI�v,[ERCIAL & RESTDENTIAL SITEWORK• ROADBU�,DZZVG S.AND & GRAVEL. DECORATIVE MATERIAI.S EQU.9L U_P.PO,Rz'UNlTYEMPLOYER Recelved Tlrr�e Mar. 6. 9: 49AM � 02/22/2007 1?: 16 95275�5e41 OFFICE ETC PAGE 01/01 � � Pl�one (763) 497-2428 P.O. Box 256 �� ° 5050 Bar�hel Industrial Dr, Fax (763) 497-3893 Albert'ville, MN 55301 � � � vwvw.dennisfchn.com � �''�vEL — E�LCA��oCs aN�. D�T� _ala��°-�__ RECEIPT AND WAiVER OF MECIIANIC'S LIrEN RIGHTS _. . . . The und.ersigncd liereby acicnowledges recei,pt of the sum of: �J I. ��a- -��-�-----from Dennis Pehn Gravel & �xcavatizzg,Inc. $-�__-- -- �---------�_ 1)---------------p�.rtial payzne�nt ,Cor labor,skill an.d t�naterial �iirnishcd. 2)___-�--------as pay�nent for all labor.,slcill and material furnishcd or to be �fitrnished (except tk�e sum of�'��-�0='�--5 a-retainage or k�oldback) 3)----------------as .fu11 and final paymettt for a111abor,skill and matcrial .furnished or to be fiirnxsiZed to the following desc.ribcd real;p.roperty: (�xoject..nazne) Pro.��r�� -+'`" and for the va1uE rece.ived hereUy waives all ri�hts acc�uired be the undcrsigned to filc or record mecbanic's licns against said r.eal property Cor all labor,slcill or rrxateri,als fumished to said real properiy(only for the amount paid if No 1 i� checiced an.d except for the retainage shown in Box 2 is ck�ecl<ed). TJ�e undersign.ed affirms tlaat ail matcrial funo,islled by tlle ux�dersigned laave bcen paid for, and al1 subcontractors employed by tlle undersigned l�ave been paid for, and all suUcontractor.s employed by tlle undersigned have Ueen paid in fu11, �XCEPT(pleasc in.seri none if no obligation is ov�ring): NOT�; Jf this instrument zs executcd by a corporation,it must be Signed by an o��cer,it' executed by a partnersllip,it must be signed by a parinEr and i�f executed by a sole proprictox,it must Ue signed Uy the so�e proprieto�-. Ir� le.. �`" $-------- - --�°=�_ ��T-,�`� s' -- - -------------- ---------- _-��- --- -- T��:- - --- - ��i y� �� ---- � Address(�--=�-----�----------�-- . �� '`-�`1 � �� 6�� COMM(E�2C.It1L & RESIDENTIAL SITEWORK� ROADI3UILDING S.AND & GRAVEL + DECORI�TNE M�ITERII�II.S ��T.JA.L OPPORTUIVITY�II7P.L0)�R Received Tlme Feb, 28, 4; 14PM WdOZ �Z '� 'arW a�� il pania�a� �.0. Bo� 256 �� Phone (763) 497-2428 5050 Bartliel Industrial Dr. � Fax (763) 497-3893 Al�bert�nlle, M�' 55301 �� w�v�v.dennisfehr�,com � C��=I. - EXCAV�TI�G nv�. DATE ��a3�o�_--- RECEYPT AND 'V'J'AxVER O�' MECHANIC'S LIEN R1f�Gr�-TTS The undersigned hereby aclrnowledges receipt of the stun of: �-� � �Oq • 01� from Dennis �'ehn Gravel 8��xcavatin Inc. $------- -� t- ------------------- g� 1)---------------partial payment for labor,skall and materia�furnished 2)-----x--�----as payrn�nt for all labor,slcill and rnaterial �urnished or to be fi.trnished (ex,cept the sum of--��D��----retainage or holdback) 3)------��--------as full and final pa�ment for alI labor,skill and rnaterial furnished or to be furnzshed to the follor�vinb described real property: (project name) , �r c�.,� r��.. �L►�-� and for the value received hereby waives all rights acquired be the undersigned to file or record r.nechanic's lzens against sa�d real property for all labor,skill or materials fiimished to said real property(only for the amount paid if No 1 is checked and e:�cept for the retainage shown in Box 2 is checkcd). The undersign�d affirms that all material fumished b� the undersig�ed ha�e been paid for, and all subcontractors employed b�r the undersigned h�ve been paid for, and all subcontractors em�loyed b�Che undersigned ha�ve been paid in full, EXCEl'T(please insert none if no obligation is owing): NOTE: If this instrument is e,cecuted by a corporation,it must be sigr�ed by an officer,if executed by a parCziership,it znust be signed by a partner and if executed by a sole proprietor,it must be signed b�the sole proprietor. � � , ` �� I__ S f;l�'V�C e. ------- --�------------------ �6-�?EE TOP LEA�?�N�, INC--- a�1��,�� ,��, Q rn��Q� DBA THEETOP:�:-f�VICE �, � -e�l f I � By:--------------^_�---- �.,. --- - 4683 65TH ..� SE p� DELANO,Mf�J 5�328 � �c/ �-�� Title: ----------------------------------- Addre ss:------------------------------------ COMMERCTAY, & T�5Tl�ENTIAL SITEWOR�i' �t,OADBUILDT1�Gr � SAND 8r GRAVEL s DECORATIVE MATERT.�T,S �f E�UAL OPPpRTUNITY EMPC,OYER _ ■ ■ ' �5�� .:� �_ MINNESOTA• REVENUE IC134 Withholding Affidavit for Contractors This affidavit must be approved by the Minnesota Department of Revenue before the state of Minnesota or any of � its subdivisions can make final payment to contractors. Please type or print clearly.This will be your mailing label for returning the completed form. �——————————— Company name 1 Daytime phone Minnesota tax ID number � ��r�ni�� -1nv. �ra,�� °� �.iCcc��a�Ti.�� c � �1:3 - �-{`i'1-:�`��`� ��7 1�3I �� IAddress I Total contract amount Month/year work began I ('. O , go� �S 4 I $ � Grd' 45 I . I c�s"I�-«o�1 I City State Zip Code I Amount still due Month/year work ended `Al►�-r�1-v�ll� C1oti rjS "3o�----J $ Cll�}Sl-I . ,� �� G' rt------ Project number Project location . o A-- ��P�E-v ��tG°��v��-t �r��z ��,;.�,1 1`��1�;-�� 11,e , ��11� �; 3 C� j � ,. — - -- —t- v �` Projr�t owner Address City State Zip code � o c�t��t ��- f�l Ia�,��-v,l�t� P, 0 . t3�x "f Fl I {��r-r ��( I �f' , t�l�� 5 s ��o ] �, � Did you have employees work on this project? �Yes �No If no,who did the work? Check the box that describes your involvement in the project and fill in all information requested. ❑ Sole contractor ❑ Subcontractor Name of contractor who hired you Address � Prime contractor—If you subcontracted out any work on this project, all of your subcontractors must file their own a IC134 affidavits and have them certified by the Department of Revenue before you can file your affidavit. For each � subcontractor you had, fill in the information below and attach a copy of each subcontractor's certified IC134. If you o need more space, attach a separate sheet. .r � Business name Address Owner/Officer o l �-e�- 10� Serv�c-e. '4io$3 1t�5-�In �= N� �1��a i�'l�� 53�`6 �b�'2c�,r� �1'1��.t' t/ � �� N Cu.rb CO��ro�ct'ofs �013'-4- ��sStL� �� t�}� �Ik��'�-r. If"1N 5533v C��,� ��ts��, Hetk�S �CA�v�^s ��1�`tC� ��nr��C._ flve �ct�CQ,U l 11P,`�''��} C SO'-1�� h ��i: �� r►P 1� ('�-+� �a r uv�S ��-1 l�l '�.�,ti. (�v��n L►n C�i e,�% P rct ct-t�s+-, l�'�(V 5(a d�I E�1,L (.i,��t[a.Y cJ-I- �1 G�t�1(JIC� �O�15"t Y_tiL--1 l C,�'� ��►�i5d �vb��n c�0�.� g�V c� �,o4e^'S�Y`ti� 55 37� 1�U.l. �{`�r�t�.✓ �- �,��V e r-�- �r��Y i��<�e s l�� :��h fl�� (�l�.`�c�;,�,� �ct�� 1�S ��`�� 54; '�� 1 declare that all information 1 have filled in on this form is true and complete to[he best of my knowledge and belief.I authorize the Department of � Revenue to disclose pertinent information relating to this project,including sending copies of this form,to the prime con[ractor if 1 am a subcontractor, d and to any subcontractors if 1 am a prime contrac[or,and to the contracting agency. r �p Contra 's signature '� Title Da e d � �i u,�,t�'v�� ,�„'��-t';'-v�.t,�� C c�'+�r<�I({',� ��7 Cl �7 Mail to: Minnesota Revenue, Mail Station 6610, St. Paul, MN 55146-6610 Certificate of Compliance Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this certificate has fulfilled a�l the requirements of Minnesota Statutes 290.92 and 290.97 concerning the withholding of Minnesota income tax from wages paid to employees relating to contract services with the state of Minnesota and/or its subdivisions. Department�(Rev nue,approv�l i'�;��•� � Da[e A ! a f� �;..,��•: i �'.;'� '��;:t. ��d e Stock No.5000134(Rev.2/03) �AR a �. �Ol MINNESOTA� REVENUE Q�� g 20� IC134 Withholding Affidavit for Contractors ', This affidavit must be approved by the Minnesota Department of Revenue before the state of Minnesota or any of its subdivisions can make final payment to contractors. Please type or print clearly.This will be your mailing laael for r�;�urning the completed farm. �Company name � Daytime phone Minnesota tax ID number � 1 r-�.�Io� ServiC� � �7 3 ni�� g 5 -- IAddre I Total contract amount Month/ye rwork began I �� S �i � � I $ 15 �33� ,GU I City te Zi Code I Amount siill due Month/ye r ork nded �— �VO—�LV�/��J $ -llv� • �C� DrV`7 -- �� P�rlect number I Proiect location � � = A- A 1 �'-,F\( C��kU�l I ��r��-�- �:�.� _�-�.°. i2��, t-1\��w�-{,��,�; 1 !\� �,`�,�, � r-�- � ,; + " ✓J J� Y . ' _'___—_.—'_—. —."_ — _. —_.— ._.—...._—_ _�_--_. � ' . �� ...a�.• 1 v. . • . . _% � Projectoc�ner Address C�?;� S_ � ZE-�� o C.e.� o� f�l b e v-t-v � ��-e. t'.� � �36x ai /''�I b�e r-1-� ��e , �t� �S�6 I a �� — c Did you ha�le employees work on this project? �Yes �No If no,who did the work? Check the box that describes your involvement in the project and fill in all information requested. ❑ Sole contractor � Subcontractor Name of contractor who hired you 17-eJv�vt�S F-z�w�- � Ya.�� +- �X Cc�v cv�--�. -. �►'�C . Addre�, � ��C d.�W ��'d2-� ��1�` l.\'� 4� V� �� Prime contractor—If you subcontracted out any work on this project, all of your subcontractors must file their own a IC134 affidavits and have them certified by the Department of Revenue before you can file your affidavit. For each +,�, subcontractor you had, fill in the information below and attach a copy of each subcontractor's certified IC134. If you o need more space, attach a separate sheet. .. v Business name Address Owner/Officer eo �+ c 0 c� 1 declare that a!1 information 1 have filled in on this form is true and complete to the best of my knowledge and belief.1 authorize the Department of � Reven to disclose pertinen[information relating to this project,including sending copies of this form,to the prime contractor if I am a subcontractor, = and ny subcontractors if I am a prime contractor,and to the contracting agency. b,p Co rac `r' gnature Title ate N : / �� o� Mail to: Minnesota Revenue, Mail Station 6610, St. Paul, MN 551 6-6610 Certificate of Compliance Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this certificate has fulfilled all the requirements of Minnesota Statutes 290.92 and 290.97 concerning the withholding of Minnesota income tax from wages paid to employees relating to contract service�tia'rth tl�e❑state of Minnesota and/or its subdivisions. Departme t8f(2evenue approval. `�°" �07 Zooc Date �� yv rT d""'' y 11. �'W"t'!_,+,'�*� �1 „� . .s'�`_ k Stock No.5000134(Rev.2/03) . � � I ��AR 0 8 20� MINNESOTA• REVENUE IC134 Withholding Affidavit for Contractors This affidavit must be approved by the Minnesota Department of Revenue befere the state of Minnesota or any of its subdivisions can make final payment to contractors. Piease type or print clearly.This will be your mailing label for returning the completed form. ————————————— �Company name � Daytime phone Minnesota tax ID number � C�4� N cv--�-�c, �ar�-rac:turs�TnC,� � �'a 588s �3� S7 IAddress I Total contract amount Month/year work began I /a/ 3 �/ o?D��`'�"�c � I � �o► l�si . od /1 I City State Zip Code I Amount still due Month/yearwo ended �� 4%�'_��"�� $ 3,G�s��+. ��=i ��j o��` Project number Project location � , I n A._ A�1 t'�F�1 ��,1-�(1�I �t'�,f'``-!- �7.�.r_ 1�� , t� --�, , ilj V"��.��- � � _ - �)V ; , , �. , ., !�. ., .� 1 � 1 V �... _ .._. ... . �. ,. . . '-� .�. � .�.�.,�'��'� .� . . ; . .. . . � � Projectowner � 1' Address City State Zipcod2� � I, a o �.e,'�=t O�- l��D e�-t-V 1 ��-� P,C , QC�X �I /=�� k�Y`1� ��e 4'"� L`� �J -r�' _� I = Did you ha e employees work on this project�Yes � If no,who did the work? ' ,•—� �-� Check the box that describes your involvement in the project and fill in all information requested. I ❑ Sole contractor il � Subcontractor I Name of contractor who hired you I��v t�s �z.vw`. � �-a��.� �- �x cc�v c9.--��, .. �n C- . Addre c�, o , �3�x a�� +��v�� \�e , �� w ��a l � Prime contractor—If you subcontracted out any work on this project, all of your subcontractors must file their ovm a IC134 affidavits and have them certified by the Department of Revenue before you can file your affidavit. For each .� subcontractor you had, fili in the information below and attach a copy of each subcontractor's certified IC134. If you o need more space, attach a separate sheet. .. v Businessname Address Owner/Officer eC i+ C O V 1 declare that all information 1 have filled in on this form is true and complete to the best of my knowledge and belief.1 authorize the Department of � Revenue[o disclose pertinent information relating to this project,including sending copies of this form, [o the prime contractor if 1 am a subcontractor, t and to any subcontractors if 1 am a prime contractor,and to contracting agency. �p Contractor's signature � , Title Date N /� ✓� / Mail to: Minnesota Revenue, Mail Station 0, St. Paul, MN 55146-6610 Certificate of Compiiance Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this certificate has fulfilled all the requirements of Minnesota Statutes 290.92 and 290.97 concerning the withholding of Minnesota income tax from wages paid to employees relating to contract services with the state of Minnesota and/or its subdivisions. Department of Revenue approval Date t ��3,�� c., �� QQ� . , Stock No.5000134(Fiev.2/03) � �IAR 0 8 200i ��, ��.� '- �� MINl�1ESOT'A• REVENUE IC134 Withholding AfFidavit for Contractors This affidavit must be approved by the Minnesota Department of Revenue before the state of Minnesota or any of its subdivisions can make final payment to contractors. Please type or print clearly.This will be your mailing label for returning the completed form. Company�ame � Daytime phone Minnesota tax ID number �---- � t1��,�e5 Fo..Y �ti'iS `Sn�. . � RS'�-y�g -Y?SS 1S3 I � y I IAddress I Total contract amount Month/year ork began � lQ7Yo �i�7vzicl� �1e' � $ �6 s4y. aa �' oy I City , State Zip Code I Amount still due Month/ ear work ended ��R�CCy�cc��,�/h�_--sso �y� $ �4�� , 3 a- �o/o y Project number Project location � , = 4-- A � !?,F�( C`�-�-C>��C,�-1- {��^,:,...Y�2. 1�,1,1�r'1 f-1�� V l �� , V""t V� 7�� - —_=—_�_ --- ---- --- - - - � � Project owner Address City Stdte Zip code a ; ��,�; o-� l�l�oe v-tv � 1�-z P,O . ��x °i /�l ti�:r--t� �1\�e , i�'i c� �536 I � Did yau h e employees work on this project? �Yes �No If no,who did the work? Check the box that describes your involvement in the project and fill in all information requested. ❑ Sole contractor � Subcontractor Name of contractor who hired you I��V1Vt\S ��Z�VW�- � Y�LV�J� � �JC CLI�iC�A��, , �ylC- � Addre�, � ��j�X �� l��'d�' �U� l,\'e . C� VV "�� J� � � Prime contractor—If you subcontracted out any work on this project, all of your subcontractors must file their own a IC134 affidavits and have them certified by the Department of Revenue before you can file your affidavit. For each +,T, subcontractor you had, fill in the information below and attach a copy of each subcontractor's certified IC134. If you a need more space, attach a separate sheet. � Business name Address Owner/Officer � w G O ' V 1 declare that all information 1 have�lled in on this form is[rue and complete to the best of my knowledge and belief.I authorize the Departmen[of � Revenue to disclose pertinent information relating to[his project,including sending copies of this form,to the prime contractor if 1 am a subcon[ractor, d and to any subcon[ractors if 1 am a prime contractor, to[he con[racting agency. t q� Contractor's si ur Title . Da e '� �rGs 1�- �a a�- 0 Mail to: Minn venue, Mail Stati 6610, t. Paul, MN 55146-6610 Certificate of Compliance Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this certificate has fulfilled all the requirements of Minnesota Statutes 290.92 and 290.97 concerning the withholding of Minnesota income tax from wages paid to employees relating to contract services with the state of Minnesota and/or its subdivisions. Departmen[of Revenue approval Date • ,i ` . � . ,` �.,r"�'�. ,V... Stock No.5000134(Rev.2/03) �"�"' -� /oo� 6 ,��R o 8 2007 . ,�IW =3 ?AR �.�� MINI�IESOT'A• REVENUE �.�`��: IC134 Withholding Affidavit for Contractors This affidavit must be approved by the Minnesota Department of Revenue before the state of Minnesota or any of its subdivisions can make final payment to contractors. Please type or print clearly.This will be your mailing label for returning the completed form. �Companyname � Daytime phone Minnesota tax ID number � I r 1� ��' F"c^._;,r w�s� Z�VI G � �Z ' ►� IAddr s� I Total contract amount Month/yea wor began I �� 7�00 ��t t��.�► �-.h I $ 33 1 SG.c:�� ICi State Zip Code I Amount still due Mont year work ended ��w��'�- s4s:.1�t'��60�1, $ � , �S�7 �c� 6✓ Os � Project number Project location � , n-� i� � '�:�\1 /�I_k("�R� '.)/^,(��,1.,�- �:r^-- � _ ti�2�_ �� '1-r��-"k�(1 � �.� �. � ��,,_` L--'C'`: 'e i � � , � , - _ . - ., . . .`_. . . . :�� -t 4 . .. -- �. . . . . � �. _ � � . . � ° ✓J ✓` 1 � �- _---- ==- ----��De--'-= • --- Project owner Address City St te Zip code a o �.eY�__-� o� �t-V ��-z P.b , QC�X � /�� }4�'I �� 536 f � Did you ha e employees work on this project? IXIYes �No If no,who did the work? �r_.. Check the box that describes your involvement in the project and fill in all information requesied. ❑ Sole contractor � Subcontractor Name of contractor who hired you ��.�1 Vl\S �Z��.✓`- � \'0.1.�e� � �X CG`�l�CA�-k.l�fy, . �1�C � Addre�s. � �'�j��C oC�W �1�'d-�'-�� ,l'e . `U� �V "�� I P � Prime contractor—If you subcontracted out any work on this project, all of your subcontractors must file their own a�- IC134 affidavits and have them certified by the Department of Revenue before you can file your affidavit. For each r subcontractor you had, fill in the information below and attach a copy of each subcontractor's certified IC134. If you o need more space, attach a separate sheet. � � Business name Address Owner/Officer _ � C O V I — — — -- I 1 declare that all information 1 have filled in on this form is true and complete[o the best of my knowledge and belief.1 au[horize the Department of , � Revenue to disclose pertinent information rela[ing to this project,including sending copies of this form,to the prime contractor if 1 am a subcontractor, t and to any subcontractors if I am a prime con[ractor,and to the contracting agency. y=p Contractor's si t - Title Date ' N �' -- � � � z �o�, Mail to: Minn ota Re ue, Mail Station 6610, St. Paul, MN 551 -6610 Certificate of Compliance Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this certificate has fulfilled all the requirements of Minnesota Statutes 290.92 and 290.97 concerning the withholding of Minnesota income tax from wages paid to employees relating to contract services with the state of Minnesota and/or its subdivisions. Department o vpn�e approval i;,"�"'- �,�;,,n,,,,,,,, Date � f" ' �� l .. .. .. . .. � � A��E � �A Stock No.5000134(Rev.2/03) � � � � � . �. .. ..... . .,._ ..e.,.�..:�o-_ .... .. °.,. ..�,.J�.�a:.:,mU ..�-.. ..e.,a„ }G.,,. ".� ... .. '�.. .r .., 4:.. . ,. .,... .�ii._, `a . � �__�:., .•,_ 't .,,,'�. ;c.:�.E<:. '-..7.�I.i..A...i. .;:.:f .is.r,`;r._r ...,....s.... . 3 C�,.;;�;'.:.w� .P! „e": r.....� .... � . �,s+ ,_.-. � .. _.. .. ��.:,. ... , '�Sa f i.. , .. ... r... .�.; ,, •'�""; �.��.. . .. ,. �.. ,.. .',, � . .�..:. ..._.C,C. ..,.;.;'S., . :::.`'. .. ..�.,... ..,� .....,... l. ... ' 01 "..,, ..:�-�t-.- �� .�� :,:. . .� . .. .-�. . . ..,.-,,, ��:,�� ''...�. . .. ., .... ... .. . .. .. ... . .FA��,, , .. .. . _. � ,. . . .,_ : . . .. .''�''L _. ' . _. , , WdLZ :Z �� qc� a�� l pan � a�a�� lof1 �t I IN N�SUTA,� R.�'�/�.i�!�f„1 E � Contractor's Withholding AfFidavit ' Confirmation NORTHDAL.E CONSTRUCTION CO INC ID 9305174 � � � � � � ' � � I � Please keep this information for your records. !, i Submit a copy of this page to the business that hired you to receive your final payment. Confirmation number 146998 Wed Feb 07 14:24�54 CS7 2007 � Project ow�er CITY OF AL6ERNILLE � project number A-ALBEV 0409 ' � � I Project begin date May 2005 ; Pro)ect end date September 2006 I Project location 2004 PP.AIRIE RUN -ALBERTVILLE, MN ' Subcon�ractors No subcontractors listed. � i I �I . - _ . . �' � . https://�rc�vvcr.mndor.state.mn.us/wc/acrion/coxa�ixmationPrint 2/7/2007 zoo �d G66�8z��9G ��1 ��y� �zsNo� ��'dQH1.dON �la 9� �zo Q��Ga��Goo� MAR08 � . �--. -�� i�� Lv�r,rt��.yti �� v�o j � �� - .�,, � n �� us � � sS •r�- vJ-e_ b�Ct:�1� i'1 c� La,� � ��/ MINNESOTA• REVENUE � � f (J v�� f �� v� IC134 Withholding Affidavit for Contractors This affidavit must be approved by the Minnesota Department of Revenue before the state of Minnesota or any of its subdivisions can make final payment to contractors. Please type or print ctearly.This will be your mailing label for returning the completed form. /Company name ` Day[ime phone Minnes�a t x IDI numb� �� - - --- I �11�V�y `i� �-Y��L6' ('15��.. I 3�U �� .� 55i5�� ? l!� i 5 �� — -._...- ----- _.._ ..----- -- -- ------ __.._ _... I Address Total contract amount Month ear work be an /Y g ' ac�cL�'�s`� f�o o ��`itln A�e N.E- � $�`� 13 3 �.°I �1 I a6��- - - ---__ _-_ ----�Y-- ___ _.._ City State Zip Code � Amount st�l due Month ear work ended -� S cl.�,t..�. 1�.Ci-l�t�S; N�'V J�. 1� l_I— —-") $--�____--- _.._.....— __.._....._. �__...1 l ��.�C}j __ —i _.......__ Project number Project location I c H� �'C.�-�'i�� D�U� �UG� r �y.Jr-� U-;•� yy r` .;'' , �— _- �. tv�ll�_ 4 "1 ' n _. _ _. -------� ---_ t__..._�—- '�_ / l� �E � I� �� .�(� � '6, ProjecTowner Address ----t- ----.-._ ---�--_ City State Zip code a � _�_ G�___�1 � -�-t� l.� (�,G C3ox_� K'E�� f+,; �� _ � � - �� o � --��-�--- �_ -��. �;�, � � _ -- -__- e Did you have employees work on this pro�ect?�Yes�No If no,who did the work? � Check the box that describes your involvement in the project and fill in all information requested. ❑ Sole contractor ?�. Subcontractor Name of contractor who hired you C�e.��v��5 ��-+n r� � r cLN�-1 J-�c Cau ci�-� '�rc . . ---- --- ---- �' Address - ------. . _......._._ _._.. _....._ ('. ��_ . �st� `__`�4-'_._ �� l b{ ��t�, �l_l r r-�N ,_� �_a_]_. � — ---.. ---- _r ___ _ -- _.. ___ __.. ❑ Prime contractor—If you subcontracted out any work on this project,all of your subcontractors must file their own IC134 � affidavits and have them certified by the Department of Revenue before you can file your affidavit. For each subcontractor � you had,fill in the information below and attach a copy of each subcontractor's certified IC134. If you need more space, `o attach a separate sheet. v Business name Address R --........_..--.._...___....-----.._.._---- Owner/Officer .. ---- - - _._.._..---- a,, --.._..._._.—_..................... c 0 c� __....__ _....___ ...__--- --- -_..__. ---.__ --------------------- �;;; _..------ � --- ---- �;;,: ----- ----- :A ��.��'&'' 4X �"!.' I decfare that all information 1 have filled in on this form is true and complete to the best of my know/edge and be/ief.1 authorize the Department of Rev- � enue to disclose pertinent information relating to this project,including sending copies of this form,to the prime contractor if I am a subcontractor,and to ,= any subcontractors if i am a prime contractor,and to the contracting agency. _...___ __ — —........_.. __..__._---------- ------------._..... . _..__.._ _..- ._......_--------------_....--- � Contractor's signature Title Date t�/ _ ----_ ...._—____.. --........... _.... —_.... ....—....--___--- -.—............ _ _ _ Maii to: Minnesota Revenue, Mail Station 6610,St. Paul, MN 55146-6610 Certificate of Compliance Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this certificate has fulfilled all the requirements of Minnesota Statutes 290.92 and 270C.66 concerning the withholding of Minnesota income tax from wages paid to employees relating to contract services with the state of Minnesota and/or its subdivisions. Department nue approval •.�., �, �� g,� Date a:: J' � �+,-�, , ,io ,k:.:�- ,�'i, ,y �� f.�L.��'- . Stock No.5000134(Rev.1/07)