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The Applicant, Martin Marietta Materials does hereby certify that Larimer County shall be compensated for any <br />damage from the proposed mining operation to the above listed structure(s) located on or within 200 feet of the <br />proposed affected area described within Exhibit A, of the Reclamation Permit Application for Three Bells Mine, <br />File Number M- 1979 -191. <br />This form has been approved by the Colorado Mined Lund Reclamation Board pursuant to its authority under <br />the Colorado Land Reclamation Act for the Extraction of Construction Materials and the Colorado Mined Land <br />Reclamation Act for Hard Rock, Metal, and Designated Mining Operations. Any alteration or modification to <br />this form shall result in voiding this form. <br />NOTARY FOR PERMIT APPLICANT <br />ACKNOWLEGED BY: IV{pt F1 it MllkeXtQ�S 1- (( ( 1 <br />Applicant, _ Representative NameV l der YYltt arl <br />Date fr? �i' Title P1eAi trtna i VP 16A <br />STATE OF ('OtISrado _) <br />ss. <br />COUNTY OF 34*A p �}�. <br />The foregoin was acknowledged before me this',,a day of 20 ][� by ���IIIIItllltllptt <br />� as v PT�,,� —_ �f btu �r 1 YWt n� a. lUittrxitL� <br />My Commission Expires: OTgR p- tp <br />Not blic <br />9 <br />NOTARY FOR STRUCTURE OWNER <br />ACKNOWLEGED BY: <br />Structure Owner &'a' E Name 1,tMZ4 Q- <br />Date Of/0B� Title 6ROAJ-11 �Ub /NFL <br />STATE OF C- l ) TIMOTHY O MEYER <br />ss. NOTARY PUBLIC <br />COUNTY OF STATE OF COLORADO <br />NOTARY ID 2013403405 <br />of Coffft don Dow M ey 31, 2017 <br />The foregoing was acknowledged before me this `� day of ,Sc�TC.rtq e►— , , <br />/ .Q �e-, j � as Lo,.±, j_� .ase - of�cl o -n4! <br />�^ My Commission Expires: S- 31 - 2ol 7 <br />Notary Publi ~ <br />