Laserfiche WebLink
DocuSign Envelope ID:7FFCOE71-7C9F-498C-9A8A-D9969FBC8D7D <br /> Cl of <br /> FoN Collins <br /> Official Purchasing Document �•�r <br /> SECTION 00670 Last updated1012017 Zt' <br /> APPLICATION FOR EXEMPTION CERTIFICATE <br /> CO{.CItADO OOMRT1N®NT OF RfYfNUE <br /> Donvw CO SM11-0009 <br /> 1 4.0.1 7 2__ 1 9 9 9-9 _ (3)MSERV 0378) <br /> Contractor Application for Exemption Certificate <br /> This exemption does not include or apply to the purchase or rental of Any unauthorized use of the exemption certificate will result in revocation <br /> equipment, supplies, and mallenals which are purchased rented, or of your exempton certificate and other penalties provxled 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,CO 80261.0009 <br /> Failure to accurately complete all boxes of the form or provide all <br /> supporting documentation vdli cause the alWicatlon to be denied. <br /> For qVartment Use Oft.Do not write in this section. <br /> Con irectoriAccount No IW"',Y ini=: <br /> tl9- <br /> Must be convilleted by applicant <br /> Contractor Information <br /> rade-nermllbeA <br /> Owner partner or corporate last name First Name t idctekwall <br /> Wiling Address City State Zip <br /> E-tiled Address Bid amount for your contract(Mist match to the penny) <br /> Fax number Business Phone number <br /> dora4owththddtngtaxa number Subsidiary i _Siabcointractora F1 StafrtigAgency <br /> (Seeinstructions) <br /> ernpi <br /> o Vectors ( ome expianrwion or attach a kner exptanahon) <br /> Exemption Information pies o contract or agreementpage,identifying contracting parties, bid amount <br /> IK type of work, and signatures of contracting parties must be attached <br /> Name of exempt organization(as show on contract) Exempt organization's number <br /> M <br /> Address of exempt organization City State <br /> Pmapol contact of exempt orgsnnzatlen--Last Name irst fine <br /> Housing Authority(if applicable Name of"act(if applicable) <br /> Owner of the Project(it applicable) <br /> Physical!oci fnn of project site(give actual address when applicable and Cites anrtbr County ties i where protect is located) <br /> City State Zip Principial con eet"s telephone nuiviber <br /> Scheouled construction%tan date Eltirfusted complebo date k,*o ; <br /> I declare tender penalty of per)Lry in the second degree that the statensents made in this application are true and <br /> ccimp)ete to the best of my cnoWed <br /> ature of the business owner partner or corporate officer Title of corporate cilflim Date mwcirri i <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 />