Laserfiche WebLink
CERTIFICATION <br /> The Applicant, �N Sfo•4) Ca,vcr e- C (print applicant/company name), <br /> by jLV c /c\nr �a.v (print representative's name),as�r eSi a�eN� (print <br /> representative's title , does hereby certify that Cj' (O reNC f_ (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 4a&,,cSfdn/ Ca,.jcre.fc (operation name), <br /> File Number M I94 Z- 0 5'l. <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 /> Lav)Si/N NGr fe, -T—VC <br /> 6y.Applicant Representative Name <br /> Date �r4kr y /, 2a(l Title ,�(QSi ete,vt <br /> STATE OF <br /> ss. <br /> COUNTY OF <br /> The foregoing was acknowledged before me this Istday of Aruar , 20 (v/, by <br /> iq�ke ka•vaSfvy as ores( e,vr of ,( AO A-1 Cc,-;-cr CIO <br /> ,,_S.v�. <br /> My Commission Expires: 1y-1[-� -2­01�y <br /> Not Public <br /> ANDREA WEBB <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20124070532 <br /> MY COMMISSION EXPIRES DECEMBER 14,2016 <br />