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• <br /> • <br /> • <br /> Contractors: please return this form to the Division with a completed Certification and Affidavit <br /> Regarding Illegal Aliens form (HB 1023 form) and for sole proprietorships, a valid Colorado <br /> Driver's License or other approved ID.*, and a Certificate of Liability Insurance. <br /> Return to: Yvonne Brannon <br /> Division of Reclamation, Mining, and Safety <br /> 1313 Sherman St., Rm. 215 <br /> Denver, CO 80203 <br /> • <br /> X--/994'- o../ Project <br /> 7,7211,1-7- o fl CT�crrUOG�YrSD'v Sy7 <br /> escnP ion " '• Unit Unit Price Amount <br /> 1. d ./efrz .6. /v‘72.- �-5 $ 17D a'- <br /> 2. $ <br /> 3. $ do <br /> • GRAND TOTAL $ ��� <br /> /'� �r}} 7� <br /> Contractor �LrttesC 372,3 !�'/�Gt�6+ r Dsate e <br /> Signature �� Phone 9.7/) (7013-50�/ <br /> -` 9 70 S'yG <br /> Address 7 774Y `.s Fax 970 a,3-5- 945-2/ <br /> Lv g/c/Ia — <br /> (42,1. <br /> • 901,11 P)DC/ <br /> *Only for contractors who are individuals or sole proprietors <br />