Laserfiche WebLink
CERTIFICATION <br />The Applicant, C-0[.c02.aAo ►M! WA05 I -Cc— (print applicant/company name), <br />by r• ; ice— -0-%4n urn (print representative's name), as(print <br />Atc-p" c.. SQ qtr: cie- <--of <br />cn a, j <br />representative's title), does hereby certify that vE (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 <br />File Number MA`1`w- I l7. <br />GvLCj {—l: t L "i 1`- L <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 r. �� Representative Nam G <br />pp L�� ��� <br />Date ��%/%S Title e7�✓� e /' <br />STATE OF Ch (p UzU, ) <br />) ss. <br />COUNTY OF��I ) <br />The foregoing was acknowledged before me this 13 day of , LA kA 20 l�, by <br />�1CJ�1Cl�l Ft a Llm aS 0.Yi �,A rv��ze31 of Q (�, �i �1r Yv �►�� <br />My Commission Expires: W 3o I -Hie <br />Notary Public <br />MEGAN G FREYSCHLAG <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 20144025710 <br />MY COMMISSION EXPIRES JUNE 30, 2018 <br />