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CERTIFICATION <br /> The Applicant, Parkerson Construction, Inc (print applicant/company name), <br /> by Alan Parkerson (print representative's name), as Vice President (print <br /> representative's title), does hereby certify that (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 C Road Pit (operation name), <br /> File Number 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: <br /> Applicant Representative Name A <br /> ZL� <br /> Date A-l- 16 Title VP <br /> STATE OF CO ) <br /> ss. <br /> COUNTY OF Meg& ) <br /> The foregoing was acknowledged before me this lsTday of Seplember , 20 1b, by <br /> AI An NArWztso✓'t as VP of PArrcers Wi &iStruCHo►i,►vic.. <br /> A kk&tlyVI&,--) My Commission Expires: $-3-1Q <br /> Notary Public <br /> LAURA L HARTMAN <br /> Notary Public <br /> State of Colorado <br /> Notary ID 19994021447 <br /> My Commission Expires Aug 3, 2019 <br />