8.d 1 2016 Street Improvements Pay Request No 4 & F...Bolton & Menk is an equal opportunity employer.
Page 1 of 1
MINNESOTA- REVENUE
Mfr T
Thank you, your Contractor Affidavit has been approved.
Confirmation Summary
Confirmation Number:
Submitted Date and Time:
Legal Name:
Federal Employer ID:
User Who Submitted:
Type of Request Submitted:
Affidavit Summary
Affidavit Number:
Minnesota ID:
Project Owner:
Project Number:
Project Begin Date:
Project End Date:
Project Location:
Project Amount:
1-360-998-720
21 -Nov -2016 12:00:35 PM
DRESEL CONTRACTING INCORP
41-1523885
kellygreene
Contractor Affidavit
8527872
3359216
CITY OF SCANDIA
2016 STREET IMPROV.
02 -May -2016
14 -Nov -2016
CITY OF SCANDIA, MN
$878,695.48
Subcontractor Summary
Name ID Affidavit Number
WARNING LITES OF MINNESOTA INC 3086922 1840201728
NORTH VALLEY INC 3744649 1444986880
SAFETY SIGNS LLC 5139558 282378240
Important Messages
A copy of this page must be provided to the contractor or government agency that hired you.
Contact Us j
If you need further assistance, contact our Withholding Tax Division at 651-282-9999, (toll-free) 800-657-3594, or (email)
withholding.tax@state.mn.us. Business hours are 8:00 a.m. - 4:30 p.m. Monday - Friday.
Please print this page for your records using the print or save functionality built into your browser.
https://www.mndor.state.mn.us/tpleservicesl /Retrieve/0/c-IUG6BGN_QIV2XEUuTbD8... 11/21/2016
11/8/2016 https:Uwww.mndor.state.mn.us/tp/eservices/_/Retrieve/0%-/dNYgDipQ3uA7_5QOM3JxRw ?FILE® Print2
MINNESOTA• REVENUE
Thank you, your Contractor Affidavit has been approved.
Confirmation Summary
Confirmation Number:
Submitted Date and Time:
Legal Name:
Federal Employer ID:
User Who Submitted:
Type of Request Submitted:
Affidavit Summary
Affidavit Number:
Minnesota ID:
Project Owner:
Project Number:
Project Begin Date:
Project End Date:
Project Location:
Project Amou nt:
Subcontractors:
0-085-872-960
8 -Nov -2016 12:21:47 PM
WARNING LITES OF MINNESOTA INC
36-4762529
wbengtson
Contractor Affidavit
1840201728
3086922
CITY OF SCANDIA
2016 ST IMP
20 -Jul -2016
20 -Jul -2016
SCANDIA
$3,946.25
No Subcontractors
Important Messages
A copy of this page must be provided to the contractor orgovernment agency that hired you.
Contact Us
If you need further assistance, contact our Withholding Tax Division at 651-282-9999, (toll-free) 800-657-3594, or (email)
withholding.tax@state.mn.us. Business hours are 8:00 a.m. - 4:30 p.m. Monday - Friday.
Please print this page for your records using the print or save functionality built into your browser.
hhps:!/www.mndor.state.mn.us/tp/eservices/ /Retrieve/O/c-/dNY9DipQ3uA7_5QOM3JxRw_?FILE_ Print2 1/1
CHISAGO CITY MINNESOTA
DRESF,1, CONTRACTING INC.
24044 JULY AVF..
CHISAGO CITY, MN 55013
PHONE: 651-257-9469
PAX: 651-257-1169
RECEIPT AND WAIVER OF MECHANIC'S LIEN RIGHTS
SUBCONTRACTOR: Warning Liles of Minnesota
CONTRACTOR: Dresel Contracting, Inc.
OWNER: City of Scandia
PROJECT: Scandia 2016 Sheet Improvemnt
STATE Number: MN
Executed this 10/21/2016
For a valuable consideration (in the amount of $3,946.25), the receipt of which is hereby acknowledged as full and final payment for
all labor, skill and material furnished or to be furnished to the above mentioned project
1. Effective upon receipt from CONTRACTOR of the amount stated to be due in said Final Request for Payment or such lesser
amount as CONTRACTOR may acknowledge to be due in accordance with the provision of the SUBCONTRACT,
SUBCONTRACTOR does now hereby absolutely waive all liens and rights or claims of lien against the PROPERTY which
SUBCONTRACTOR ever had, has or may have, and does release the CON'T'RACTOR and OWNER from any claim, liability or debt
by reason of labor, services, equipment, materials and rentals which have been or will be performed or furnished by
SUBCONTRACTOR to or for the Project under the SUBCONTRACT, including, without limitation, all "claims", "changes", "extras"
and other charges of any description.
2. SUBCONTRACTOR further represents and certifies that no lien has been filed against the PROPERTY by SUBCONTRACTOR or
any laborer, sub -subcontractor or material -man who has directly or indirectly fiu•nished labor, services, equipment, rentals or materials
to or for the PROJECT under the SUBCONTRACT, and the SUBCONTRACTOR has paid all bills, taxes (including applicable Sales
and Use Taxes) and charges at the agreed prices for all of said labor, services, equipment, rentals and materials which have been or are
to be furnished to or for the PROJECT under the SUBCONTRACT.
3. In firrther consideration of such payment, Warning Liles of Minnesota. releases and forever discharges Merchants Bonding
Company, as Surety, ffom any and all claims, demands, actions, causes of action or suits of whatsoever kind of nature against the
bond issued by Merchants to Dresel Contracting, Inc. as principal, bond no# MNC 106438930
4. SUBCONTRACTOR authorizes CONTRACTOR to complete any blank spaces in this Document.
Note: If this instrument is executed by a corporation, it must be signed by an officer, and if executed by a partnership, it must be
signed by a partner, Limited Liability Company, it trust be signed by a member and/or officer.
Warning Liles of Minnesota
(Subcontractor)
By:
Owner, Partn , Off ) (Please Designate)
tNoAc Mc Nv
(Address)
Page 1 of 1
Contractor Affidavit Submitted
Thank you, your Contractor Affidavit has been approved
Confirmation Summary
Confirmation Number:
1-362-383-168
Submitted Date and Time:
8 -Nov -2018 3:53:64 PM
Legal Name:
NORTH VALLEY INC
Federal Employer ID;
41-1906523
User Who Submitted;
northva
Type of Request Submitted:
Contractor Affidavit
Affidavit Summary
Affidavit Number:
1444986880
Minnesota ID:
3744649
Project Owner;
CITY OF SCANDIA
Project Number:
N/A
Project Begin Date:
24 -Jun -2016
Project End Date:
14 -Sep -2016
Project Location;
2016 ST, IMPS-SCANDIA
Project Amount:
$376,511.86
Subcontractors:
No Subcontractors
Important Messages
A copy of this page must be provided to the contractor or government agency that hired you.
Contact Us
If you need further assistance, contact our Withholding Tax Division at 651-282-S999, (toll-free) 800.6573594, or (email)
withholding.taxQstate,mmus. Business hour$ are 8:00 a.m. - 4:30 p.m. Monday - Friday,
Please PtQthig a for your records using the print or save functionality built into your browser.
. https://www.mndor.state.rnn.us/tp/ese;rvices/_/Retrieve/O/c-/4iPQvv ESY2rlhTbN'rD2ag_. .. 11/8/2016
ZOO/Z00' d vosz fLZ 69L(xv:o Dul ADINA LIVON OS:9 L 9 L OZ/801 L L
CHMAGO MI NP$QTA
DRESEL CONTRACTING INC:
24044YULYAVE,
CHISAC30 CITY,M.N 55()1.3
PHOND'1651257-9469
FAX' 651-2.57-1169
RTLCL, JYT. AMI) WAIVER OF MECHANIC'S LMN RIGHT'S
SUBQ,QNTR.ACTOP,: North Valley .1 hip -
CONTRACTOR: Dres:el Contractim, Tnc.,
OWNER: City -of, Sean.dia
'PROIECT. ScaadJa 2'016 Street hi�provamm
STATE Number: MN
Executed this LI /7/16
For a valuable con8ideratioxi (iT.1 the
mnount.of$3765,11,8.6), the
e of whichis hereby acknowledgpd as full and final payment for
all laboj:, skill and material furnished or t6. be. mem.tioned project
1. Effeetive upaurecefpt from stated, to: be.due in sPi.d' Ffi)41. Request for Payment or such lesser
ov
arfiounta-z.lCONT-RACTAO,Riitay'aGI.c.now,ledge-to.-bedu*ein,gcoortlancewit4t!iep' 'Won of th�a SUB CONTRACT,
SUBCONTRACTOR does now hereby absolutely *a,ivp- all liens and dghts -oi- claims oflien:ag . ahipt the PROPERTY whiA
SUBCONTRACTOR ever had, has or:iDay Dave,. and, 4.o,6s release a)e ObN�T- R -A, CTQR-. alid: O.WNER fi,om a 1o*Wm, liability or -debt,
y
SUBCONTRACTOR,to cr,far the Project under rhe SU8CONTRACT, ft),cJadigg, WAput limitation,
"changes", "extras
and other charges of Any descrl,ptkm.
2, SUBCONTRACTOR, further Tidli has been ;fled-qainst-the PROPE]kTY bySUKQ.NTRACTOR.or
any laborer., SA-SLibcontr4dtoror inateflal-man who has directly or inditectly furnialled labor, sei-vices, eqW ment, rentals or . p3aterials
-P
to of fbi- the PROJECT under E"he SUBCONTRACT, and thdSU) ' 3CON-T�,A.QT0R'hp Paid all bill's, taxes (Includbig applicable Sales
and Use Taxes) an<l
d chaps ' .at the. agreed prices P61'all of said Jabdr, services; equipment, which haVe been or are
to be fumished to or for the; P-WEOT under ffie 50B.CON- MCT,
I In fai:thor coms'ideration of such paynlMT, North Valley Inc, releases aAd for &.v.
Or discharges Merehaa�ts Betiding Company, as
Surety, from any And all 'claims, deb=ds, actions, ,causes of action or suits -of whatsoever kitid -of nature against the bond issued by
Merchants to Dresel Contracting, Inc, as.*priftcipdl, bond -no# M.NC 1*0'6438930
4. SUBCONTRACTOR authorizes CONgTRACTOR to complete an"Y blank space's in this Document.
Note: Uthis ffistrameV.Is execrated by 4'porpovatibn'it must bb bY' an officer,, and if executed by d partnorft,, it must. be
signed by a piav(jiqr, Limited Liability Company it,niast bt signed by'a. meurbeL and/6t officer.
North. V2116y Inc
.(SubccntrActor)
By:
-tnet,, 'Of6cei) (Please Dasignate}
,�740 J,4 /pW 111,o Id <,
(Address)
ZOOMO'd POE VLZ EDL(XVI)
■
Dul ADINA 44JON OS: 9 L 9 L OZISO/ L L
11/10/2016 16:03 9524696689 SAFETY SIGNS PAGE 02/02
DRESEL CONTRACTING. INC,
24044. JULY AVE.
CHISAGO CITY, MN 55013
PHONE: 651-257-9469
FAX; 651-257-1169
_>vC1~IkT AND WAIVER OF MECHANIC'S LIEN RIGHTS
SUBCONTRACTOR: Safety Signs
WNTRACTOR: Dresel Contxaating, Ino,
OWNER: City of Scandia
PROJECT: Scandia 2016 Street Improvemnt
STATE Number: MN
Executed this 11/7/16
For a valuable consideration. (in the amount of $3517.50), the receipt of which is hereby acknowledged as full and final payment for
all labor, skill and material furnished or to be furnished to the above mentioned project
1. Effective upon receipt fxora CONTRACTOR of the amount stated to be due in said Final Request for Payment or such lesser
amount as CONTRACTOR may acknowledge to be due in accordance with the provision of thf, SUBCONTRACT,
SUBCONTRACTOR does now hereby absolutely waive all liens and rights or claims of'lien against the PROPERTY which
SUBCONTRACTOR ever bad, bas or may have, and does release the CONTRACTOR and OWNER from any claims, liability or debt
by reason of labor, Services, equipment, materials and rentals which have been or will be performed or furnished by
SUBCONTRACTOR to or for the Project under the SUBCONTRACT, including, without limitation, all "claims", "changes", "extras"
and other charges of any description.
2. SUBCONTRACTOR further represents and certifies that no lien has been filed against the PROPERTY by SUBCONTRACTOR or
any laborer, sub -subcontractor or material -man who has directly or indirectly furnished labor, services, equipment, rentals or materials
to or for the PROJECT under the SUBCONTRACT, and the SUBCONTRACTOR had paid all bills, taxes (including applicable Sales
anal Use Taxes) and charges at the agreed prices for all of said labor, services, equipment, rentals and materials which have been or are
to be.fumished to or for the PROJECT under the SUBCONTRACT -
3. In further consideration of such payment, Safety Signs. releases and forever discharges Merchants Bonding Company; as Surety,
from any and all claims, demands, actions, causes of action or suits of whatsoever kind of nature against the bond issued by Merchants
to Drescl Contracting, Inc. as principal, bond no# 1v1NC 1,0643$930
4. SUBCONTRACTOR authorizes CONTRACTOR to complete any blank spaces in this Document.
Note: If tbis instrument is executed by a corporation, it must be signed by an officer, and if executed by a partnership, it must be
signed by a partoer. Limited Liability Company, it must be signed by a member and/or officer.
Safety Signs
(Sribcontractor)
By:
er, er, Officer) (Please esrgnate)
(Address)
11/10/2016 16:03 9524696689
MINNESOTA® RWfNUE
Contractor Affidavit Submitted
Thank you, your Contractor Affidavit has been approved
Confirmation Summary
Confirmation Number:
1-272-828-224
Submitted Date and Time:
1allov-2016 4:15:07 PM
Legal Name:
SAFETY SIGNS LLC
Federal Employer ID:
41-1991774
User Who Submitted:
sue blanchard
Type of Request Submitted:
Contractor Affidavit
Affidavit Summary
Affidavit Numbor:
Minnesota ID:
Project Owner:
Project Number:
Project Begin Date:
Project End Date:
Project Location:
Project Amount:
Subcontractors:
282375240
5139558
CITY OF SCANDIA
NA
1G -May -2016
21-Ju1-2016
SCANDIA 2016 STREET IMPROVEMENT
$3,517.00
No Subcontractors
SAFETY SIGNS
Important Messages
A copy of this page must be provided to the contractor or government agency that hired you.
Contact Us
If you need further assistance, contact our Withholding Tax Division at 651-252 9999, (toll-free) Soo�57-3594, or (email)
withholding.tax(ostate.mmus. Business hours are 8:00 a.m_ - 4:30 p.m. Monday - Friday -
Please print this p for your records using the print or save functionality Will into your browser.
PAGE 01/02
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11 /10/9.016