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X ///' �_-• �Siness'i lust f ax : . � 21 Form Ea - Minnesota Department of Revenue 0 Withholding. Affidavit for Contractors This affidavit must be approved by the Minnesota Department`of Revenue before the State of Minnesota or any of its subdivisions can make final payment to contractors. C RV" na+ti Minneaaa ID number Laughlin Electric Co. 5922479 Addrou Monlhyaar wont boor+ 980 North Dale St. 11-90 COY ataie zw Code Ho"aar wont enda0 St. Paul Minnesota 55117 1-91 Tow om+Uad amount: 38,530.00 Tewphor a nurrber Anwrit stat due: 612 ) - 489-1303 6,021.00 Did you have employees work on this project? yes Project number. 14027.01 If none,explain who did the work: Project k�cadon• St. Anthony,Well Projectownbr: St. Anthony, City of Address 3301 Silver Lake Road Chock the box that describes your Involvement In the project and fill In all Information requested In that category: ❑ Soto contractor ❑ Subcontractor If you are 4a subcontractor,fill in the name and address of the contractor that hired you: 49 Prime Contractor If you subcontracted out any work on this project,all of your subcontractors must file their own IC-134 affidavits and have them certified by the Department of Revenue before you can file your affidavit. For each subcontractor you had,fill in the business information below,and attach a copy of each subcontractor's certified IC-134. (If you need more space,attach a separate shoot.), Business name Address Owner/Officer Bostroan Sheet Metal 785 Curfew St. , St. Paul, MN 55114 • Layne Minnesota Co. 3147 California St. N.E. , Mels. , MN 55418 Larry Alberg D.S, Trudeau Const. 1385 Farrrdale Rd. , St. Paul, MN 55118 Hank Trudeau I all nrtnmom I declare that all Information 1 have filled In on this form is true and oompleta m the beat of my knowledge and bellel. 1 suthorizs the Deparvnent of Revenue to disclose pertinent information relating m this project•Including sending copies of this forth, to the pritne contractor if I am a subc6ntraaor,and to any subcontractors If I am a prime contractor,and to the contracting agency waoorti alprrture nb President For certification,mail to: Minnesota Department of Revenue,Business Trust Tax Section Mail Station 6610,St.Paul,MN 55146-6610 Certificate of Compliance with Minnesota Income Tax Withholding Law sed on records of the Minnesota Department of Revenue. I certify that the contractor wh o has signed this certificate has Wag3es illed all the requirements of Minnesota Statutes 290.92 and 290.97 concerning the withholding of Minnesota Income tax from paid to employees relating to contract services with the state of Minnesota and/or its subdivisions. Signidum of ALA orbrrd Depanrrrnt d Revenue oncW ' Y n a �4t)1