HomeMy WebLinkAbout109445 CONNELL RESOURCES INC - CONTRACT - BID - 5482 ASPHALT OVERLAY PROJECT 2000 (3)DR 0172 (12/99)
COLORADO DEPARTMENT OF REVENUE
DENVER CO 10261
(303) 232-241E,
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CONTRACTOR APPLICATION
FOR
EXEMPTION CERTIFICATE
Pursuant to Statute
Section 39-26 114(1)(a)(M)
DO NOT WRITE IN THIS SPACE
The exemption certificate for which you are applying must be used only for the purpose of purchasing construction and building
materials for the exempt project described below This exemption does not include orapplyto the purchase or rental of equipment,
supplies, and materials which are purchased, rented, or consumed by the contractor and which do not become a part of the
structure, highway, road, street, or other public works owned and used by the exempt organization
Any unauthorized use of the exemption certtficate will result In revocation of your exemption certificate and other penalties provided
by law
A separate certificate Is required for each contract
Subcontractors will not be issued Certificates of Exemption by the Department of Revenue It is the responsibility of the prime
contractor to Issue certificates to each of the subcontractors (See reverse side)
FAILURE TO ACCURATELY COMPLETE ALL BOXES WILL CAUSE THE APPLICATION TO BE DENIED.
RegistrationlAccount No (to be assigned by DOR) I
89 - _
Period
0170-750 (999) $0.00
CbN'TRACTOR INFORMATION
,
Trade name/DBA
Owner partner, or corporate name
Mailing address (City, State, Zip)
Contact Person
E-Mall address
Federal Employer's Identification Number Bid amount for your contract
Fax number
Business telephone number Colorado withholding tax account number
EXEMPTION INFORMATION Copies oteontractoragreementpages(1)iiientityingthecontractingparties
and (2) containing signatures ofconirai3ing parties must be attached.`:
Name of exempt organization (.as shown on contract)
Exempt organization's number
�38
Address of exempt organization (City, State, Zip)
Principal contact at exempt organization
Principal contact's telephone number
Physical loc ation of project site (give actual address when applicable and Litres andfor County (tes) where project is located)
Scheduled Month Day Year
Estimated Month Day Year
construction start date
completion date
I declare under penalty of pequry in the second degree that the statements made /n this application are true and
complete to the best of my knowledge
Signatuie of owner, partner or c orporate officer Title of corporate officer
Date
DO NOT WRITE BELOW THIS LINE