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1 <br />I herek:y depose and state under the penalties of perjury that all <br />statements, proposals and/or plans submitted with or contained within <br />this application are true and correct to the best of ny knowledge. <br />COUNTY OF Ne:ld <br />STATE OF Colorado \ 1 <br />Signature: Owner/Authorized Agent <br />' Subscribed and sworn to before ^e this ~'• day of `' ,`;j1~4 <br />y <br />'.. <br />SEAL _ ,'J'et ~ ~ <br />NO ARY PUBLIC '•;i ,rl,•0.~`p•i•s <br />Hy Commission expires: ~ .- ~, j'•-•~ <br />•..•. u ~ <br />1 <br />1 <br />1 <br />1 <br />