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PERM ITTE E/STRUCTURE OWNER AGREEMENT <br /> Mine: Native/Pierre Mine-M-1977-321 <br /> State of Colorado, Mined Land Reclamation (MLR) law requires the permit applicant(operator/permittee)to agree <br /> to reimburse the owner of any permanent man-made structure(s)within 200 feet of the permitted mining area, for <br /> damage done to the structure(s) as a result of the permitted operation. <br /> Summit Brick and Tile Co. believes Lilly M Zampacorta own the following structure(s), located within 200 feet of <br /> the permitted mining area: House, Fence <br /> Summit Brick and Tile Co. agrees to reimburse you for any damage done to the listed structures as a result of the <br /> mining operation. Your acknowledging signature and a notary seal in the spaces provided below shall satisfy the <br /> MLR law requirement. Summit Brick and Tile Company certifies this agreement as follows: <br /> CERTIFICATION: The Applicant Summit Brick and Tile Co. represented by Matthew R. Welte as CEO, does <br /> hereby certify that Lilly M Zampacorta shall be compensated for any damage from the proposed mining operation <br /> to the above listed structure(s) located within 200 feet of the permitted mining area described in the MLR Permit <br /> for the Native/Pierre Mine. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEDGED BY: <br /> Permit Applicant: Summit Brick and Tile Co. P.O. Box 533 Pueblo 81002 <br /> Representative: Matthew R. Welte CEO-719-542-8278 <br /> Signature: hILSt, �U C /2'WZY( Date: 5 f`�.�'l Zo <br /> STATE OF Colorado ) <br /> ) ss <br /> COUNTY OF Pueblo ) <br /> The foregoing was acknowledged before me this day of 2020, by <br /> Matthew R.Welte as CEO of Summit Brick&Tile CO. <br /> Notary Public J�k/�` �r '//_'_�y Commission Expires: <br /> A CLEMENTI <br /> NOTARY PUBLIC I <br /> STATE OF COLORADO <br /> NOTARY FOR STRUCTURE OWNE NOTARY ID 20144043949 <br /> MY COMMISSION EXPIRES NOVEM13ER 13.20221 <br /> ACKNOWLEDGED BY: <br /> Structure Owner(s): Lilly M Zampacorta <br /> Signature: . '``l �' Date: G7 <br /> t <br /> r <br /> STATE OF 0610�Q�o ) <br /> t )SS <br /> COUNTY OF l D ) �}} <br /> The fo egoin was ackno edgg,ed before me this day of 20)0, by <br /> i liq ZU m 060cf <br /> Notary Public: My Commission Expires: <br /> _a �_zazz, <br /> DEBRAA.GARNER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 19984000234 <br /> MY COMMISSION EXPIRES 01.05:2022 <br /> SENT TO STRUCTURE OWNER VIA CERTIFTED MAIL 11 70192970000082391240 <br />