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10-2020-062 Paue <br /> -7 - <br /> Certification: <br /> As an authorized representative of the applicant,I hereby certify that the operation described has met the minimum requirements of the <br /> following terms and conditions: <br /> I. All necessary approvals from local government have been applied for(Section 34-32.5-110(1)(a)(VIII). <br /> 2. To the best of my knowledge,all significant,valuable and permanent man-made structure(s)in existence at the time this <br /> application is filed, and located within 200 feet of the proposed affected area have been identified in this application <br /> (Section 34-32.5-115(4)(e).C.R.S.). (NOTE: For 110 operations,the affected area includes all lands delineated by the permit <br /> boundary.) <br /> 3. No mining operation will be located on lands where such operations are prohibited by law (Section 34-32.5-115(4)(f), <br /> C.R.S.). <br /> 4. As the applicant/operator,I do not have any mining/exploration operations in the State of Colorado currently in violation of <br /> the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials(Section 34-32.5-120.C.R.S.). <br /> 5. 1 understand that statements in the application are being made under penalty of perjury and that false statements made herein <br /> are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503,C.R.S. 1984. <br /> This form has been approved by the Mined Land Reclamation Boardpursuant to section 34-32.5-110,C.R.S.,of the Colorado Land <br /> Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form shall result in voiding any <br /> permit issued on the altered or modifed form and subject the operator to cease and desist orders and civil penalties for operating <br /> without a permit pursuant to section 34-32.5-123, C.R.S. <br /> Signed and dated this_ day of JANUARY AD 2021 <br /> O'Rourke Excavating, Inc. If Corporation Attest(Seal) <br /> Applidant/Operator o <br /> Signed: .tat; fi Signed: ° <br /> Corporate Secretary or Equivalent <br /> Title: Thomas O'Rourke, President Towrt/City/County Clerk <br /> State of Colorado ) <br /> )ss. <br /> County of Rio Grande ) <br /> The foregoing instrument was acknowledged before me this day of JANUARY, 2021 <br /> by Thomas O'Rourke, as President of O'Rourke Excavating, Inc. <br /> .°� 77 <br /> ;ODY L. JONES Rotary'Pwubli - <br /> Notary Public <br /> Mate of Colorado �1""f 3`L <br /> �a;4ary ID#201 14058454 i My Commission expires: <br /> �ofrtia3�ior,Expires 09.13-2021 <br /> SIGNATURES MUST BE IN BLUE INK <br /> 7 <br />