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-8- <br />Certirtcation: <br />As an authorized representative of the applicant. I hereby certify that the operation described has nut 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 arc prohibited by law (Section 34-32-115(4)(t), C.R.S. <br />1984, as amended): <br />3. As the applicant/operator. i do not have any ntininglprospecting 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 ofperjury and that false statements made herein are <br />punishable as a Class 1 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,CR.S.. of the Alined Lund <br />Reclamation Act. Ail' aheralion or modification of this form shall res till in voiding ani,permit issued on the altered or modified form <br />and subject the operator to cease and desist orders and civil penallies for operating without a permit pursuant to section 34-32-123, <br />C. R.S. <br />Signed and dated this .,14a M day of ? <br />ApplicantlOperator Name <br />Signature, By: ??? - F _ <br />Title: ? <br />C Gam//"r(-c C" ) <br />State of <br />j? ) SS. <br />County of Snit ?l e' y a ) <br />Cotter Corporation, N.S.L. If Corporation Attest (Corporate/County Seal) <br />IA- <br />rporate Secretary or Equivalent 4 _ <br />5; may. <br />Presi ent Co,-gV5i? ? <br />own/City;County Clcrk <br />The foregoing instrument was acknowledged before me this day of w? .4/0 <br />by 4as..,el 'o f <br />?Notary Public <br />< JENNIFER R. LEAR IM`, Commission expires: 7. -Jo 4a - <br />1. COMM41807112 ?.J <br />NOiARV puK, C • CAUFOOM <br />SAfi'f31600 COUNTY <br />Comm.. IµlG.17 2012