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Fort Cottins
Community Development & Neighborhood Services
281 N College Ave. P.O. Box 580
Fort Collins, CO 80526
Phone 970-416-2740 Fax 970-224-6134
CERTIFICATION OF MINERAL ESTATE OWNER NOTIFICATION
PROJECT NAME: o // 41� iy/GG ,�- 600YI
CITY OF FORT COLLINS FILE NUMBER:
❑ The undersigned does hereby certify that the developer/applicant for the above
named Application for Development in the City of Fort Collins has provided
notice as required pursuant to Section 24-65.5-103 of the Colorado Revised
Statutes to any owner or lessee of a mineral estate underneath a surface estate
that is subject to the Application for Development, or that the developer/applicant
has obtained a waiver of the right to notice from any such mineral estate owner.
❑ If a waiver has been obtained, a copy thereof must be attached to this certificate.
Indicate by checking the box if attaching a copy of the waiver signed by all
mineral estate owners.
Indicate by checking the box if the undersigned certifies that the mineral estate
has not been severed from the surface estate for the above named Application
for Developme �����
Applicant's Signaturetj�
State of Colorado )
) ss.
County of ,r r, ^ )
Acknowledged before me this ` \16A�l day of , 20_10 by
Witness my hand and official seal
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Ngta*' Public
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My commission expires: eV) Qnt4 400-00.
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