8.d 2 2016 Crack Filling & Seal Coat Pay Request No...Bolton & Menk is an equal opportunity employer.
11/16/2016 https://www.mndor.state.mn.us/tp/eservices/ /Retrieve/0/c-NgmsBwY3CbUfDh_CBrRMrg_?FILE= Print2
Contractor Af i avis Submitted
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:
0-650-629-440
16 -Nov -2016 12:10:43 PM
ALLIED BLACKTOP COMPANY
41-0827871
N10503
Contractor Affidavit
752140288
8606387
CITY OF SCAN DIA
N13.111404
08 -Aug -2016
06 -Oct -2016
VARIOUS ROADS AND STREETS
$112,058.10
Subcontractor Summary
Name ID Affidavit Number
AAA STRIPING SERVICE CO 6290097 989995008
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 651-282-9999, (toll-free) 800-657-3594, or (email)
withhold ing.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.
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Page 1 of 1
MINNESOTA- REVENUE
Contractor Affidavit Submitted
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:
Subcontractors:
0-644-329-792
16 -Nov -2016 8:23:24 AM
AAA STRIPING SERVICE CO
41-0997871
Kelly Shirley
Contractor Affidavit
989995008
6290097
CITY OF SCANDIA
2016 SEALCOAT
06 -Oct -2016
06 -Oct -2016
SCANDIA
$2,585.80
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 651-282-9999, (toll-free) 800-657-3594, or (email)
with holding.tax@state.mn.us. Business hours are 8:00 a.m. - 4:30 p.m. Monday - Friday.
Please t3ririt this naoe for your records using the print or save functionality built Into your browser.
https://www.mndor.state.mn.us/tp/eservices/ /Retrieve/0/c-/6i_JEtg6YdItagI7X2zyWw ... 11/16/2016
RECEIPT AND WAIVER
OF MECHANICS LIEN RIGHTS
The undersigned hereby acknowledges that upon payment in full from Allied
Blacktop Company, for striping services purchased from the undersigned
delivered or furnished to (or performed at) City of Scandia, MN for 2016 Crack
Filling & Seal Coat Project and for value received hereby waives those rights
which may have been acquired by the undersigned to file mechanics liens
against said premises on account of the above described labor and/or materials
delivered and furnished by the undersigned, to the extent only of the amount of
the aforesaid payment: and the undersigned hereby expressly reserves the right
to assert, without prejudice to it's heretofore existing priority, mechanics lien
rights against said premises for labor and/or materials delivered and/or furnished
to said premises payment for which is not included in the aforesaid payment.
Dated this ) I — I , 2016.
Title:_ -
AAA Striping Service Co.
12220 43rd Street NE
St. Michael, MN 55376
(763) 428-4322
RECEIPT AND WAIVER
OF MECHANICS LIEN RIGH S
The undersigned hereby acknowledges that payment has
from Allied Blacktop Company, for FA -2 Trap Rock
undersigned delivered or furnished to (or performed at) Cit
for value received hereby waives those rights which may h
the undersigned to file mechanics liens against said premi
above described labor and/or materials delivered an
undersigned, to the extent only of the amount of the afore:
undersigned hereby expressly reserves the right to assert
it's heretofore existing priority, mechanics lien rights agai
labor and/or materials delivered and/or furnished to said K
which is not included in the aforesaid payment.
Dated this qday of , 2016
Title:
been received in full
purchased from the
of Scandia, MN and
lve been acquired by
;es on account of the
J furnished by the
aid payment: and the
without prejudice to
est said premises for
remises payment for
Dresser Trap Rock Inc.
P.O. Box 517
Dresser, WI 54009
(800) 537-3573
WAIVER AND RELEASE OF LIEN
WHEREAS, the undersigned, Flint Hills Resources, LP, has furnished to iRL+
—Co ctn ("Contractor"), the following product: CRS -
Name 2
of Contractor Name of Product
sold pursuant to Contract number �b�i , between the
Enter Flint Hills Resources, LP Contract Number
dates of UY1 l andAuys+_15 , 2016 , for use in the construction of a
project belonging to
Name of Municipality, County, or State
designated as �y
Project Number or Name
(the "Project"), and
NOW THEREFORE, Flint Hills Resources, LP, for and in consideration of at least
$ �.L, and other good and valuable consideration, the receipt whereof is hereby
acknowledged, do(es) hereby waive and release any and all liens, or right to claim of lien, on
the Project and premises, under any law, common or statutory, on account of labor or
materials, or both, heretofore or hereafter furnished by Flint Hills Resources, LP, to or for the
account of said Contractor for the Project.
Given under my hand, this
Flint Hills Resources, LP
Kim Woodbridge
Credit Manager
1 day of bo v � - , 201(o.
11/14/2016 15:50
NOV-14-2016(MON) 12 41
5074273709
Allied blacktop
MIDSTATES EQUIPMENT
(FAX)763 d25 IM
RECEIPT AND WAIVER
OF MECHANICS ITN RIGHTS
The undersigned hereby acknowledges that payment has been received in full
from Allied Blacktop Company, for Fight Pointe 340513723, road sealant
purchased from the undersigned delivered or furnished to (or performed at) City
of Scandla, MN and for value received hereby waives those rights which may
have been acquired by the undersigned to file mechanics liens against said
promises on account of the above described labor and/or materials delivered and
furnished by the undersigned, to the extent only of the amount of the aforesaid
payment. and the undersigned hereby expressly reserves the right to assert,
without prejudice to it's heretofore existing priority, mechanics lied rights against
said premises for labor and/or materials delivered and/or furnished to said
premises payment for which is not included In the aforesaid payment.
Dated this day of OYJA&Y , 2016.
Q 1 -
By:
o ce 2J lo 6
Title: C.0
Midstates Equipment & Supply
606 County Rd. #1
Mountain Lake, MM 56159
(507) 427-3607
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