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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. https://www.mndor.state.mn.us/tp/eservices/ /Retrieve/0/c-NgmsBwY3CbUfDh_CBrRMrg_?FILE_=Print2 1/1 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 PAGE 01/01 K OO2/D02