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7/07/200S Hill 7:31 FAI 952 937 6910 IID9EST ASPBALT CORP.@001/003 <br />MINNESOTA Department of Revenue <br />Withholding Affidavit for Contractors ic-isa <br />This affidavit must be approved by the Minnesota Deportment of Revenue before the state of <br />Minnesota or ony of ih subdivisions con make Pmoi payment to contractors. <br />m ffeose type or print dearty. This wHt be your matting tobd hr retvmhg the compteted hr,u <br />Cempeny momm <br />I MIDWEST ASPHALT CORPORATION I <br />1 Addreti <br />I P.O. BOX M77 <br />■ssKoai <br />ICJiy <br />vHO <br />Peyfiete phone <br /><952 '937-8033 <br />Minneido wilhkolding kui 10 ftvrr«^gr <br />7252554 <br />Tolol ccAlroct omouni .Monrti/yoor %rofk bf^n - <br />Monrh/yaor wdryendecT <br />fro|Mt nutnbw <br />i <br />froi«cl locoiion <br />BIRCH LANE STORM SEWER TRAIL CONSTRUCTION <br />City <br />si <br />fro|«cl ownft< Addrvis <br />CITY OF ORONO. 2750 KELLY ^RKWAY. ORONQ, MINNESOTA 55323 <br />\ Did you l«av« empioymt work on ihii proHwf? Q No no, who did iK« Mforki <br />Siotc Zip code <br />Check the box thot describes your involvement in the project and fill in all information requestad <br />Q Sole contractor <br />(Z) Subcontroctor <br />No<iw of coiMrocior who kirod you <br />Addrou <br />M <br />■;4 U <br />life! <br />[3 Wwt® ciMitractor—If you lubcontraclod oui any work on this project, all of your subcontroctors must file their own <br />lOl 34 affidavits and have them certified by the Department of Revenue before you can file your ofTidovit. For each <br />fubcontroctor you had, fill in the infomotion below arid attach a copy of each subcort’’nctor'i certified 1C*134. If you <br />need more space, aitoch a seporote sheet. <br />imitie Addr^iS _____Ov^rwryofftcof____ <br />-r? <br />CURB MASTERS INC.. 600 W POPLAR STREET. STILLWATER MINNESOTA SS082 <br />F.P. JEDLICKI. INC.. 14203 W62ND STREET. EDEN PRAIRIE MINNESOTA 5S346 <br />-(AS;f V <br />t deelore that ott Uiformalhn I koto kthd in on this form n mm and compUh to the best of my knowtedge and bcttmf t ouihonze the Deporfmont of <br />Rmjmm to di^sm poninme tnhnnotlon rehling to this profoct, indbdkig sending copies ofthis form, to ihm prone conSoctor if tom o tubeonvodor. <br />9i)d lo anjMwfccantaelora ifloMe ptim»j>^aet^, ondlorimceniiochng oguncy. <br />TilS^ <br />CONTRACT ADMINISTRATOR <br />ing OiviiioirMoil Station 6610. Si. Pool. MN 55166-6610 <br />Certificate of Complionce <br />Based on records of the Minneioto Deportment of Revenue, I certify that the controdoc who hos signed this certificote has <br />fulfilled oil the requirements of Mmnesoio Stofwfes 290.92 ond 290.97 concerning the withholding of Minnesota mcome tox <br />from woges poid lo employees reloting io controct services willi the stote of Minnesota and/or its subdivisions. <br />oF Revenue opprouol ^ <br />Hi <br />J24647.max <br />-