2013-04-01_PERMIT FILE - M2013018 ‎(2)‎

• Permit No: M2013018
• IBM Index Class Name: PERMIT FILE
• Doc Date: 4/1/2013
• Doc Name: 110c Appl.
• From: Pine Bluffs Gravel & Excavating, Inc
• To: DRMS
• Media Type: D
• Archive: No

Street address 324 3rd St
Ault
(The fiillowing statement is adopted by marking the box.)
(City)
(City)
6. (If applicable, adopt the following statement by marking the box and include an attachment.)
❑ This document contains additional information as provided by law.
(Street number and name)
CO 80610
(State) (ZIP Code)
Mailing address
(leave blank if same as street address) (Street number and name or Post Office Box information)
CO
(State)
The person appointed as registered agent above has consented to being so appointed.
(ZIP Code)
5. The date the entity commenced or expects to commence transacting business or conducting activities in
Colorado is 05/01/2013
(mm /dd / }yyy)
7. (Caution: Leave blank if the document does not have a delayed effective date. Stating a delayed effective date has
significant legal consequences. Read instructions before entering a date.)
(If the following statement applies, adopt the statement by entering a date and, if applicable, time using the required format.)
The delayed effective date and, if applicable, time of this document is /are
Notice:
Causing this document to be delivered to the Secretary of State for filing shall constitute the affirmation or
acknowledgment of each individual causing such delivery, under penalties of perjury, that the document is the
individual's act and deed, or that the individual in good faith believes the document is the act and deed of the
person on whose behalf the individual is causing the document to be delivered for filing, taken in conformity
with the requirements of part 3 of article 90 of title 7, C.R.S., the constituent documents, and the organic
statutes, and that the individual in good faith believes the facts stated in the document are true and the
document complies with the requirements of that Part, the constituent documents, and the organic statutes.
This perjury notice applies to each individual who causes this document to be delivered to the Secretary of
State, whether or not such individual is named in the document as one who has caused it to be delivered.
8. The true name and mailing address of the individual causing the document to be delivered for filing are
Lonny
(Last)
PO Box 609
Graves
(First)
(mm/dd/yyyy hour:minute am/pm)
(Street number and name or Post Office Box information)
(Middle) (Suffix)
Pine Bluffs WY 82082
(City) (State) (ZIP /Postal Code)
United States.
(Province — if applicable) (Country)
(If the following statement applies, adopt the statement by marking the box and include an attachment.)
❑ This document contains the true name and mailing address of one or more additional individuals
causing the document to be delivered for filing.
AUTHORITY Page 2 of 3 Rev. 12/01/2011