Laserfiche WebLink
CERTIFICATION <br /> The Applicant, O "CL GN (print applicant/company name), <br /> byyprint representative's name), as ot0t-�e I eeC.5;1ZE07' (print <br /> representative's title),does hereby certify that Q, (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 _ AGE t 1: 60 TE (operation name), <br /> File Number <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 fora:shall resrtlt in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applican�7�(, Representative Name <br /> Date Title <br /> BLAKELY CALLAHAN <br /> STATE OF NOTARY PUBLIC•STATE OF COLORADO <br /> ss. Notary ID#20184029309 <br /> COUNTY OF ) My Commission Expires 7/19/2022 <br /> r <br /> The foregoias acknowledged before me this ,e �day of ov, )4 1K,201 ,by <br /> Wy-ge— <br /> ash of 7'7 b4? 'T:t 2! ( �- Co. <br /> My Commission Expires:_7Z`I _ <br /> Notary Public <br />