2017-04-10_PERMIT FILE - M1980244

• Permit No: M1980244
• IBM Index Class Name: Permit File
• Doc Date: 4/10/2017
• Doc Name Note: Application for a proposed Map Change to CCMOD
• Doc Name: Permit Document
• From: Newmont / CC&V
• To: DRMS
• Email Name: TC1
• Media Type: D
• Archive: No

(10-08-2009)
LAND USE APPLICATION FORM
Teller County Community Development Services
Post Office Box 1886 • Woodland Park, CO 80866
[phone] • FAX: [phone]
W PROJECT NAME: Cripple Creek & Victor Gold Mining Company: M-1980-244/Amendment 11
tX APPLICATION FEE AMOUNT (must be attached): $630
PROPERTY OWNER (please print) -
IF MORE THAN ONE PROPERTY OWNER, ALL PROPERTY OWNERS MUST BE LISTED (attach list)
Name: Cripple Creek & Victor Gold Mining Company
Mailing Address: P.O. Box 191, Victor, CO 80860
Phone: Office: [phone] Home:
Fax: [phone] Email Erik. Munroe(-newmont.com
® (1) TITLE COMMITMENT, TITLE GUARANTEE, TITLE COMPANY OWNERSHIP & ENCUMBRANCE
REPORT, OR ATTORNEY'S TITLE OPINION; OR
❑ DEED(S) as required
IX ADJACENT PROPERTY OWNERS LIST names & addresses
® ADJACENT PROPERTY OWNERS MAILING LABELS
KI MINERALS INTEREST FORM AND LIST as required
XI SPECIFIC APPLICATION SUBMITTAL MATERIALS
APPLICANT= 4F DIFFERENT FRbM PROPERTY OWNER (please print)
Name: Same as above
Mailing Address:
Phone: Office: Home:
Fax: Email:
U WRITTEN, NOTARIZED, AUTHORIZATION AND CONSENT FROM ALL PROPERTY OWNERS FOR
AUTHORIZED AGENT TO ACT ON THEIR BEHALF
Page 1 of 4
TYPE -OF APPLICATION
CHECKANE
❑
Amended Final Plat
❑
Special District
❑
Amendment to Official Zone Map (Rezone)
❑
Special Exemption Plat
❑
Combined Sketch/Preliminary (/Subdivision)
❑
Special Review Use Permit:
U
Combined Sketch/Preliminary (PUD)
❑ Conditional Use for
U
Final Plat
❑
Interior Lot Line Vacation
❑
Location & Extent
U
Minor Infill Subdivision
❑ Special Use
❑
Preliminary Plan (Subdivision)
for
U
PUD (Sketch or Preliminary)
U
1041
U Sketch Plan (Subdivision)
❑
Zoning Variance
21
Other: CCMOD Map Change
W PROJECT NAME: Cripple Creek & Victor Gold Mining Company: M-1980-244/Amendment 11
tX APPLICATION FEE AMOUNT (must be attached): $630
PROPERTY OWNER (please print) -
IF MORE THAN ONE PROPERTY OWNER, ALL PROPERTY OWNERS MUST BE LISTED (attach list)
Name: Cripple Creek & Victor Gold Mining Company
Mailing Address: P.O. Box 191, Victor, CO 80860
Phone: Office: [phone] Home:
Fax: [phone] Email Erik. Munroe(-newmont.com
® (1) TITLE COMMITMENT, TITLE GUARANTEE, TITLE COMPANY OWNERSHIP & ENCUMBRANCE
REPORT, OR ATTORNEY'S TITLE OPINION; OR
❑ DEED(S) as required
IX ADJACENT PROPERTY OWNERS LIST names & addresses
® ADJACENT PROPERTY OWNERS MAILING LABELS
KI MINERALS INTEREST FORM AND LIST as required
XI SPECIFIC APPLICATION SUBMITTAL MATERIALS
APPLICANT= 4F DIFFERENT FRbM PROPERTY OWNER (please print)
Name: Same as above
Mailing Address:
Phone: Office: Home:
Fax: Email:
U WRITTEN, NOTARIZED, AUTHORIZATION AND CONSENT FROM ALL PROPERTY OWNERS FOR
AUTHORIZED AGENT TO ACT ON THEIR BEHALF
Page 1 of 4