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1 certify that, as the owner of the property listed on this form, I have contacted the LGU and <br /> coniact person listed on this form, aild a WCA replacenlent plan: <br /> ❑has been ol�tai�ed, o�� <br /> ❑ is not rcquired, <br /> for the work described and at the location listed on this form, ' <br /> � <br /> Propez•ty Owner Naiue � <br /> Sig��ature D�te <br /> i <br /> � <br /> � <br /> Contractor Owner Name i <br /> i <br /> Signatiu•e Date � <br /> I <br /> L.ocal Government Unit (LGU): <br /> Address: Phonc: � <br /> � <br /> LGIJ Person Contacted; <br /> Tliis statement is invalid if any uf the�tbove information is not sup�lied or is inaccuratc. <br /> Worlc in violation of Minncsota Stxtutcs § 103G.2212 to � 103G237 is a misdemeatior <br /> punishaiblc by up to a �700 finc:�nd )0 days in,jail. <br /> ;. <br /> N_OTE: Keep a capy'of tfiis forrn fot..your records, and send � <br /> � : #he o'riginal to the,;Local Gover"nm:�nt Unit. >;,: <br /> Nage 2 ot'2 <br /> 131��SR_Form_1uCA__Ei2lorcemrnt__5(Cont_Kes��on) (Ap�•il 2003)) ; <br /> I <br />