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i <br /> CERTIFICATION <br /> The applicant, Oldcastle SW Group, Inc. , represented by Rich Umbel <br /> as, President does herby certify that Ted Franciscotti, Ben Franciscotti and Cindy <br /> Fransciscotti (structure owners) shall be compensated for any damage from the proposed mining <br /> operation to the above listed structure(s) located on or within 200 feet of the proposed affected <br /> area described within the Reclamation Permit for Franciscotti Pit, File Number M-2018-058. <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its authority under the <br /> Colorado Land Reclamation Act for the Extraction of Construction Materials and the Colorado Mined Land <br /> Reclamation Act for Hard Rock, Metal, and Designated Mining Operations.Any alteration or modification to this <br /> form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEDGED BY: (Signature of Officer) <br /> Applicant Oldcastle SW Grop, Inc. Representative Name: Rich Umbel <br /> Date: C(- 1-T— _-�DaI Title: President <br /> STATE OF 7::- <br /> )ss. <br /> COUNTY OF <br /> The foregoing was acknowledged before me this rl day of ':�.4 , 20 21,by <br /> ut � as"cUS r A g,� of d 6rA4, <br /> MyExpires: ,.p1A�df HEIDI R. VEACH <br /> Commission Z Commission Number 701199 <br /> Notary Public °W' . January 14, 202 res <br />