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DocuSign Envelope ID:7FFCOE71-7C9F-498C-9A8A-D9969FBC8D7D <br /> city ofr <br /> Fy Collins Official Purchasing Document Fir 1 <br /> xr r.i rd last updated 102017 --> <br /> SECTION 00670 <br /> APPLICATION FOR EXEMPTION CERTIFICATE <br /> II IIIIIIIIIIIlillllll11111110I IIIIII1 i Dany C W261-0000 <br /> COLORADO DEPARTIAErtT OF REVENUE <br /> 1 4 01 7 Z 19990 I (3o3j 2SERV 0379) <br /> Contractor Application for Exemption Certificate <br /> This exemption does not include or apply to the purchase cr rental of Any unauthorized use of the exemption certif icate wtil result in revocation <br /> equipment, supplies, and m atenals which are purchased, rented, or of your exemption certificate and other penalties provided 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, Deriver, CCU£10261.0009 <br /> Failure to accurately complete all boxes of the form or provide all <br /> supporting documentation will cause the aEplicatlon to be dented. <br /> For D artment Use Only.Do not write in this section. <br /> Olttractprl todrtt No efig0;tltrra'-rdtG r� <br /> Must be co hated by applicant <br /> Contractor Information <br /> Trade nametDBA <br /> Owner.partner or corporate last name First Name Middle initial <br /> Mailing Address city State Zip <br /> E-Mad Address FEN Bid amount for you r contra ct(Must match to the penny) <br /> Fax number Business Phone number <br /> Colorado withholding tax account number I Subsidiary . I Subcontractors Stsifng Agency <br /> (sac instructions) <br /> No em eslsubcontractors see tRbow7 <br /> o mployees ubcontractors I once explanation or attach a letter cir explanation) <br /> Copies of contract or agreement page, ldenufving the contracting parties, bid amount; <br /> Exemption Information type of work, and signatures of cortracttng partles must be attached <br /> Name of exempt organization(es show on contract) Exempt organl2ation's number <br /> 198 <br /> Address of exempt organization city State Zip <br /> papal contact st exempt orgenizarlon-Lost Name First Name Middle rupiah <br /> Housing Authority Rif applicable) Name of Project(if applicable) <br /> Owner of the Project(if applicable) <br /> Physical location of protect sde(give actual afters when apr*cnble and Cities"lot County hest where protect is located) <br /> city State Zip Rrincdpal contact's telephone number <br /> Scheduled construction titan Estimeted corrpleli0n date,'kimcf:.- i <br /> I 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 knoWed <br /> Signature of the business owner,partner or corporate oifrcer Title of corporate otri er pate crt r. <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 />