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(10-03-2009) <br /> LAND USE APPLICATION FORM <br /> Teller County Community Development Services <br /> Post Office Box 1886* Woodland Park, CO 80866 <br /> (719) 687-3048 * FAX: (719)687-6256 <br /> TYPE OF APPLICATION (CHECK ONE) <br /> 0 Amended Final Plat 0 Special District <br /> n Amendment to Official Zone Map (Rezone) 0 Special Exemption Plat <br /> 0 Combined Sketch/Preliminary(/Subdivision) 0 Special Review Use Permit: <br /> I] Combined Sketch/Preliminary(PUD) 0 Conditional Use for <br /> 0 Final Plat <br /> 0 Interior Lot Line Vacation <br /> 0 Location & Extent <br /> [I Minor Infill Subdivision Special Use <br /> [I Preliminary Plan (Subdivision) for <br /> [I PUD(Sketch or Preliminary) 0 1041 <br /> 0 Sketch Plan (Subdivision) U Other: <br /> 0 Zoning Variance <br /> U PROJECT NAME: Littlo Grouse Overtook <br /> 0 APPLICATION FEE AMOUNT(must be attached): $1,500.00 <br /> PROPERTY OWNER(please print) <br /> IF MORE THAN ONE PROPERTY OWNER,ALL PROPERTY OWNERS MUST BE LISTED(attach list) <br /> Name: Cripple Creek and Victor Gold Mining Company LLC, <br /> Mailing Address: Post OfficsBox 191,Victor,Colorado 80860 <br /> Phone: Office: 719-6894022 Home: NA <br /> Fax: Email <br /> 0 (1)TITLE COMMITMENT,TITLE GUARANTEE,TITLE COMPANY OWNERSHIP&ENCUMBRANCE <br /> REPORT,OR ATTORNEYS TITLE OPINION;OR <br /> Ej DEED(S) as required <br /> Er ADJACENT PROPERTY OWNERS LIST names&addresses <br /> �ADJACENT PROPERTY OWNERS MAILING LABELS <br /> B"'MINERALS INTEREST FORM AND LIST as required <br /> D SPECIFIC APPLICATION SUBMITTAL MATERIALS <br /> APPLICANT-IF DIFFERENT FROM PROPERTY OWNER(please print) <br /> Name: -3.4 6c..j <br /> Mailing Address: - ?-0. got- 14 6.— cc) 0'F fe C> <br /> Phone: Office: 10 "1 (Zjl!t Home: <br /> Fax: Email: y sA. Lc=ft <br /> 2/WRITTEN,NOTARIZED,AUTHORIZATION AND CONSENT FROM ALL PROPERTY OWNERS FOR <br /> AUTHORIZED AGENT TO ACT ON THEIR BEHALF <br /> Page 1 of 4 <br />