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The Applicant, <br />CERTIFICATION <br />SPRAGUE STONE LLC <br />by MATTHEW SPRAGUE (print representative's name), as <br />representative's title), does hereby certify that N/A <br />(print applicant/company name), <br />VICE PRESIDENT <br />(print <br />(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 />Permit Application for SPRAGUE STONE <br />File Number M - <br />(operation name), <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: <br />Applicant /" i+ta4zVnev v Representative Name <br />Date Rb IZ - 70 1 Title <br />STATE OF Oo /o, -a to ) <br />J ) ss. <br />COUNTY OFi/}7P/ ) <br />The foregoing was acknowledged before �je this /-Z day of `Pbraal- , 20 �, by <br />Y�hecc� J 40 U4 as ✓L'c f'/C5,c�Plt,�_ of _Q9,,e <br />My Commission Expires: <br />Notary Pu c <br />MINDY G ZSCHEILE <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID # 20074029596 <br />MY COMMISSION EXPIRES AUGUST 02, 2015 <br />