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The Applicant, Cooley & Sons Excavating, Inc. (print applicant/company name), <br />b James Cooley (print representative's name), as President/Owner (print <br />representative's title), does hereby certify that (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 Pepper Pit (operation name), <br />File Number M- 2011 034 <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 />ACKNOWLEGED BY: <br />Applicant <br />D <br />STATE OF d)&i.Zdk,) <br />COUNTY OF <br />) ss. <br />CERTIFICATION <br />NOTARY FOR PERMIT APPLICANT <br />Representative Name <br />Title President <br />U <br />tit <br />The � going was acknowledged before me this day of �zhvitt/'7 , 20 � 1 , by <br />as of <br />My Commission Expires- <br />James Cooley <br />