HomeMy WebLinkAbout129564 TRAINOR CONSTRUCTION - CONTRACT - BID - 5730 TAFT HILL ROAD BRIDGE OVER NEW MERCER DITCH (3)DR 0172 (12198)
COLORADO DEPARTMENT OF REVENUE
DENVER CO 80261
(303)232-2416
CONTRACTOR APPLICATION
FOR
EXEMPTION CERTIFICATE
Pursuant to Statute
Section 39-26.114(1)(a)(M)
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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 or apply to 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 certificate 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. ft is the responsibility of the prime
contractor to issue certificates to each of the subcontractors. (See reverse side.)
FAILURE TO ACCURATELY COMPLETEALL BOXES WILL CAUSE THE APPLICATION TO BE DENIED.
RegistratiorVAccwunt No. (to be assigned by DOR)
Period
0170-750 (999) $0.00
89 -
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Trade name/DBA: -
Owner, partner, or corporate name:
Mailing address (City, State, Zip):
Contact Person
E-Mail address:
Federal Employer's Identification Number.
Bid amount for your contract:
$
Fax number: -
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Business telephone number.,
Colorado withholding tax account number:
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Name of exempt organization (as shown on contract): Exempt organlzetion's number.
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Address of exempt organization (City, State, Zip):
Principal contact at exempt organization: tacts telephone number. Principal con
Physical location of project site (give actual address when applicable and Cities and/or County (]as) where project Is located) -
Scheduled Month Day Year
Estimated Month Day Year
construction start date:
completion date:
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I declare under penalty of perjury in the second degree that the statements made in this application are true and
complete to the best of my knowledge.
signature of owner, partner or corporate officer.
Title Of corporate officer.
Date:
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