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I> <br />CERTIFICATION <br />The Applicant, Ka <br />g.ar,, av i -)ry L L L (print applicant/company name), <br />by e eC« G \ (print representative's name), as in em.� -e-i (print <br />representative's title), does hereby certify that C� S7 r Cou structure owner) shall <br />be compensated for any damage from the proposed mining operation to the above listed structure(s) <br />located on or within 200 feet of the proposed affected area described within Exhibit A, of the Reclamation <br />J <br />Permit Application for O L-J k i l * (operation name), <br />File Number M -M�- �. <br />This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br />authority under the Colorado Land Reclamation Act for the Extraction of Construction Materials and <br />the Colorado Mined Land Reclamation Act for Hard Rock, Metal, and Designated Mining Operations. <br />Any alteration or modification to this form shall result in voiding this form. <br />NOTARY FOR PERMIT APPLICANT <br />ACKNOWLEGED BY: jj /� <br />Applicant LC Representative Name c7e <<� G n <br />Date Z7 �l� Title / 'lo fn <br />STATE OF I OF-A O'D ) <br />ss_ <br />COUNTY OF ) <br />The foregoing was acknowledged before me this r/-L day of A u , 20G5�, by <br />bP cct ktaqgn as IY CMbe- r of t�ACI„a 0 ct. ,,oL So n , 4-1-6 <br />454blUa,%Aa,Q-2,�. My Commission Expires: -D 9 'a7—ao % & <br />lcl <br />r <br />NE C ygs.o <br />• t� <br />NOTARY <br />p�JgL1C : o <br />0 <br />OF GO <br />