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The Applicant, Ra, Vfrineai SU V�t� Lte (print applicant/company name), <br />by ( 4 (print representative's name), as 4414 612,112,q) 4 1 '& (print <br />representative's title), does hereby certify that id , cr N l i nivo (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 Bulldog Mountain Operation, <br />File Number M- 1977 -215. <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 />Date <br />6 /7/Zdi <br />STATE OF @ iv)(c b <br />4 ) ss. <br />` mi <br />COUNTY OF l il ) <br />The foregoing was acknowledged before me this . day of <br />1 i as j Prt- aviat rai. <br />Notary Public <br />BIZ Lattitki942.4ihu <br />CERTIFICATION <br />NOTARY FOR PERMIT APPLICANT <br />Representative Name <br />Title Ate• tt 619 14e/4/ <br />My Commission Expires: ) I U ' 'v. 0) 3 <br />, 20.,, by <br />of LbY <br />5i Nur) <br />