Laserfiche WebLink
CERTIFICATION <br /> The Applicant,J&JeaI N l d U ✓4U I✓j �.J� Z4 0 (print applicant/company name), <br /> byL (print representative's name), as President (print <br /> representative's title), does hereby certify that (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 Mineral Mountain Project (operation name), <br /> File Number M 2014.045 <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 form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> r� l <br /> Applicant � 1� l7 b� presentative Name h C <br /> Date �� a��, Title (� <br /> STATE OF - oyv-G ) <br /> • ) ss. <br /> COUNTY OF <br /> The foregoing as acknowledged before me this day of A , 20-,-� by <br /> as of >� ' <br /> ".4e'00 M <br /> y Commission Expires: 0 <br /> 6jtar�y Public <br /> Q <br /> M <br />