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C ERTIFI(ATION <br /> The Apphcaiit. SEMA Construction,Inc. aprint applicant c0111pany name 1. <br /> by Mark Brooks District Vice President sprint <br /> __ ___ ____izpirseutau e';titlel_sioe;l>erzb} :�,tity that Cliff Betz titru tune O-.rner) shall_ <br /> be compensated for any damage from the proposed iitiitinp operation to the above listed structure(i) <br /> located on or within 200 feet of the proposed affected area described within Exhibit A.of the Reclamation <br /> Pennit Application for Betz Borrow Pit (operation name). <br /> File Number M- - <br /> This form has been approved bt•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 dined Land Reclamation Act for Hard Rock,Metal,and Designated Alining Operations. <br /> Any alteration or modification to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNONVLEGED BY: <br /> Applicant SEMA Construction,Inc. Representative Name <br /> Date (S/zd 12-0 t 8 Title District Vice President <br /> STATE OF ruck ) <br /> I ss. <br /> COL�tTY OF 6t�ly� <br /> tot"ry'�il <br /> ins was aeknon ledged before me this(. day of AlfGus 20 .by <br /> ✓-v S ashalric Wive f, ,l Af c+ k�My Coimiussion Expires: /O//lic <br /> NANCY T GUERRERO <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20124067633 <br /> MY COMMISSION EXPIRES 10119/2020 <br />