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CERTIFICATION <br /> The Applicant, Cripple Creek & Victor Gold Mining Company (print applicant/company name), <br /> by Jack Henris (print representative's name), as General Manager (print <br /> representative's title),does hereby certify that_ ,//���le �►�. (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 Cresson Project (operation name), <br /> File Number M-1980-244 <br /> This farm 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 form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICAtNT <br /> ACKNOWLEGED BY: <br /> Applicant O� IIv Vl rl Representative Name <br /> Date "� 7 f c�c) —� Title C�E}AevimVIC-C er <br /> STATE OF���C)� C� ) <br /> ss. <br /> COUNTY OF YA(ey� ) <br /> r— <br /> Th fore oin was acknowledge -before me Z day of - ��-)L ,2 l��by� <br /> as w1C " " of <br /> t VAC L� <br /> akgZ2 My Commission Expires: <br /> Notary ublic <br /> PENNY MARIE ROBERTS <br /> Notary Public - State of Colorado <br /> Notary 10 20124056348 <br /> My Commission Expires Oct 3, 2020 <br />