2017-10-11_PERMIT FILE - M2017012

• Permit No: M2017012
• IBM Index Class Name: PERMIT FILE
• Doc Date: 10/11/2017
• Doc Name: Special Use Permit Application
• From: Amazonite Mining, LLC
• To: DRMS
• Email Name: ERR
• Email Name: WHE
• 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]
TYPE OF APPLICATION (CHECK ONE)
❑ Amended Final Plat ❑ Special District
❑ Amendment to Official Zone Map (Rezone) ❑ Special Exemption Plat
❑ Combined Sketch/Preliminary(/Subdivision) ❑ Special Review Use Permit:
❑ Combined Sketch/Preliminary(PUD) o Conditional Use for
❑ Final Plat
❑ Interior Lot Line Vacation
❑ Location & Extent
❑ Minor Infill Subdivision %. Special Use
❑ Preliminary Plan (Subdivision) for Nntm.,1.1Q (r1
❑ PUD (Sketch or Preliminary) � !`�`= T\O t' F�\— t o L-
❑ Sketch Plan (Subdivision) 0 1041
❑ Zoning Variance El Other:
yr PROJECT NAME: r r;.,:' f ;. J.
❑ APPLICATION FEE AMOUNT(must be attached): . ,C3
PROPERTY OWNER(please print)
IF MORE THAN ONE PROPERTY OWNER,ALL PROPERTY OWNERS MUST BE LISTED(attach fist)
Name: SD ;; f;•.J\C L , K c3r.1 (: s
Mailing Address: O (CS( F 2',9 A)R?L_ , c
Phone: Office: 1G, - f
� Home:
Fax: Email
❑ (1)TITLE COMMITMENT,TITLE GUARANTEE,TITLE COMPANY OWNERSHIP&ENCUMBRANCE
REPORT,OR ATTORNEY'S TITLE OPINION; OR
• DEED(S) as required
❑ ADJACENT PROPERTY OWNERS LIST names&addresses
❑ ADJACENT PROPERTY OWNERS MAILING LABELS
❑ MINERALS INTEREST FORM AND LIST as required
❑ SPECIFIC APPLICATION SUBMITTAL MATERIALS
APPLICANT- IF DIFFERENT FROM PROPERTY OWNER(please print)
Name: A 1'�lt `
F�ZO.ti� t � � r'✓; ►is 1/,-1 C_
Mailing Address: " C-')5.--t j.V EP-‘ E7—.)OPE----11-1.2—, \ T T��i o>~t , CO F1)(3\7_71,
Phone: Office: .• -• -1\-.3 C) Home: 3 C(3 — Z4-00 `C.
Fax: Email: J�o�r�sc�j5��t-eS�.QrJ
❑ WRITTEN, NOTARIZED,AUTHORIZATION AND CONSENT FROM ALL PROPERTY OWNERS FOR
AUTHORIZED AGENT TO ACT ON THEIR BEHALF
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