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DocuSign Envelope ID:7FFCOE71-7C9F-498C-9A8A-D9969FBC8D7D <br /> city of <br /> 1of C I <br /> �.• O1 ` oUi I n IS Official Purchasing Document <br /> SECTION 00670 Last updated 1012017 -- <br /> APPLICATION FOR EXEMPTION CERTIFICATE <br /> Ii11i1i0IIIIIi iiiiIMimIll IIiIl'II COLOR <br /> {rJra101118) <br /> COt.OriADO OE'H4R1'I11110 t OF REVENUE <br /> 1 0009 <br /> 4 01 7 2 1 9 9 9 9 Deriver CO ERV 4-79) <br /> (9Q31?3rB-SERV{737Bf <br /> Contractor Application for Exemption Certificate <br /> This exempt n does not include or apply to the purchase or rental of Anyunauthorized use of the exemption certificatewill result in revocation <br /> equipment, supplies, and materials which are purdtased, rented, or ofyour exemption certificate and other penalbes praoded by law, <br /> consumed by the contractor and which do not become a part of the A separate certificate is required for each contract <br /> structure,highway,road,street,or other public works Owned and used <br /> by the exempt organization <br /> Send completed forms to:Colorado Department of Revenue, Denver, GO 80261.0009 <br /> Failure to accurately complete all boxes of the form or provide all <br /> supporting documentation will cause the U2111cation to be denied. <br /> For D artlment Use Only.Do not write in this section. <br /> Contractor taunt No period iMn•r-rnuwri <br /> f�- <br /> Must be comilpilleitted by appilcant <br /> Contractor Information <br /> Trade nameMEA <br /> Owner.partner or corporate last name Furst Name Middle trial <br /> Molting Address City State Zip <br /> E-Mad Address FSN B)d amount for your contract(Mist match to the penny) <br /> Pax nunter Busintss Prone number <br /> C;iorado wit holding tax account numbiw Subsidiary I Subcontractors Srafrng Agency <br /> (See instrucbons) <br /> No empjgnesAabcontractors see below <br /> No mploye ubceniractors (Provide a%plan as oft or ettach a letter of expianatlon). <br /> Copies of contract or agreement page, identifying the contracting parties, bid arriount, <br /> Exemption Information type of work, and signatures of contracting parties must be attached <br /> Name otexempt organization(as show on contract) Exempt orgenrzation's number <br /> tt$ <br /> Address of ever pt organization City state Ip <br /> ;rnncipal contact M exempt organizatlon-Lost Name First Name Muddle Ma <br /> -lousing Authority(if appWabte) Name of Project(if applicable) <br /> Owner of the Project(if soplitable) <br /> prrysicol location of prgect sdc(give actual adthtss when apperatble and Cities smuor County Iles)where profed is located) <br /> City State Zip Prinrapal contact's telephone number <br /> he4uled construction start ante t,,4m,c xa t Estimated compiels>ar+date.:i,mccv,ri <br /> t declare under penalty of perjury in the second degree that the statements made in this application are true and <br /> complete to the best of my knoWedge <br /> Segnature of the business aver,partner or corporate otficer Title of corporate officer Sate ft <br /> Services Agreement—Work Order Type <br /> RFP 9227 CM/GC Services for Lemay Ave Realignment over the BNSF Railroad Tracks and Vine Dr Page 31 of 123 <br />