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-8- <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 /> 1. This mining operation will not adversely affect the stability of any significant,valuable and permanent man-made structure(s) <br /> located within two hundred(200)feet of the affected lands. (However,where there is an agreement between the applicant/operator <br /> and the persons having an interest in the structure that damage to the structure is to be compensated for by the applicant/operator <br /> (Section 834-32-115(4)(d),C.R.S. 1984, as amended), then mining may occur within 200 feet. Proof of an agreement must be <br /> submitted to the Office prior to the decision date.) <br /> 2. No mining operation will be located on lands where such operations are prohibited by law(Section 34-32-115(4)(f), C.R.S. <br /> 1984,as amended); <br /> 3. As the applicant/operator,I do not have any mining/prospecting operations in this state of Colorado currently in violation of the <br /> provisions of the Mined Land Reclamation Act(Section 34-32-120,C.R.S. 1984,as amended)as determined through a Board <br /> finding. <br /> 4. 1 understand that statements in the application are being made under penalty of perjury and that false statements made herein are <br /> punishable as a Class I misdemeanor pursuant to Section 18-8-503,C.R.S. 1984,as amended. <br /> This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32-112,C.R.S., of the Mined Land <br /> Reclamation Act Any alteration or modification of thisform shall result in voiding any permit issued on the altered or modified form <br /> and subject the operator to cease and desist orders and civil penalties for operating without a permit pursuant to section 34-32-123, <br /> C.R.S. QQ <br /> �- <br /> Signed and dated this Z 21 day of ✓ �2( <br /> Colorado Legacy Land, LLC If Corporation Attest(Corporate/County Sea]) <br /> Applicant/Operator Name <br /> Signature: By: <br /> M ag� g P a rt n e r Corporate Secretary or Equivalent <br /> Title: Town/City/County Clerk <br /> State of Colorado ) <br /> ss. <br /> County of Larimer ) Q <br /> The foregoing instrument was acknowledged before me this A day of <br /> James Managing Colorado Legacy <br /> by Harrington as Partner of Land, LLC <br /> JOS UA WARNE <br /> NOTARY PUBLIC <br /> STATE OF COLORAW Notary Public <br /> NOTARY ro 20194036323 Gl��H l�3 <br /> W COMMISSION ED(PIRESSEPTEMBER24.2M My Commission expires: <br />