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-8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of the <br />following terms and conditions: <br />1. This mining operation will not adversely affect the stability of any significant, valuable and permanent man -made structure(s) <br />located within two hundred (200) feet ofthe affected lands. (However, where there is an agreement between the applicant/operator <br />and the persons having an interest in the structure that damage to the structure is to be compensated for by the applicant/operator <br />(Section 834- 32- 115(4xd), C.R.S. 1984, as amended), then mining may occur within 200 feet. Proof of an agreement must be <br />submitted to the Office prior to the decision date.) <br />2. No mining operation will be located on lands where such operations are prohibited by Iaw (Section 34- 32- 115(4)(1), C.R.S. <br />1984, as amended); <br />3. As the applicant/operator, I do not have any mining/prospecting operations in this state of Colorado currently in violation of the <br />provisions of the Mined Land Reclamation Act (Section 34 -32 -120, C.R.S. 1984, as amended) as determined through a Board <br />finding. <br />4. I understand that statements in the application are being made under penalty ofpedury and that false statements made herein are <br />punishable as a Class 1 misdemeanor pursuant-to Section 18 -8 -503, C.R.S. 1984, as amended. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32-112, of the Aflned Land <br />Reclamation Act Any alteration or modification of this form shall result in voiding any permit issued on the altered or modifted form <br />and subject the operator to cease and desist orders and civil penalties for operating without a permit pursuant to section 34-32 -123, <br />C.R.S <br />Signed and dated this _'3 L ^ day of <br />Fortune Revenue Silver Mines, Inc. .: <br />Applicant/Operator Name <br />Signature: <br />Title: <br />) ss. <br />County of `Y'v`, cN ,!� ` - _'j%_ ) <br />If Corporation Attest (Corporate/County Seal) <br />By: <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />The foregoing instrument was acknowledged before me this day of <br />by . ; :' 'i . .' J - - of ,�. Jam.:. %,�. y'`•? Si�:�'� y ��'.. T r. <br />I " <br />Notary Public <br />B.13RIAN SWAN My Commission expires- it, k- r�. s �•, �� y �' ' ;;; : w.^ .ir , <br />Berl WW & Soll&tor <br />100 FUIIWton Sbvd <br />Lmdon, Out. NMI K1 <br />