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CERTIFICATION <br /> The Applicant, Loveland Ready-Mix Concrete, Inc. (print applicant/company name), <br /> by Brad Fancher (print representative's name),as President (print <br /> representative's title),does hereby certify that Netson Farrltty Residence(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 Dunn Pit (operation name), <br /> File Number M 2021-059. <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- 7 <br /> Loveland Ready-Mtx <br /> Applicant Concrete, Inc Representative Name <br /> Date �-�� !2 Title President <br /> STATE OF CIO ) <br /> � __"" )ss. <br /> COUNTY OF {aN�VT\ZA ) <br /> The f__oreg``oin was acknowledged before me this/[ day of r'' 202�by 1 r <br /> ►oz Yl C�tAa2_ as S( of 1� <br /> My Commission Expires: 6U OV <br /> Not ry Public —� <br /> JOAN E HORST <br /> Notary Public <br /> State of Colorado <br /> Notary ID 8 19944018967 <br /> M Commission Expires 11-21.2022 <br /> NOTARY FOR STRUCTURE OWNER <br /> ACKNOWLEGED BY <br /> Structure Owner Name <br /> Date Title <br /> STATE OF ) <br /> )ss <br /> COUNTY OF ) <br /> The foregoing was acknowledged before me this_day of 20_,by <br /> as of <br /> My Commission Expires <br /> Notary Public <br />