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Fort�,ollins
Community Development & Neighborhood Services
281 N College Ave. P.O. Box 580
Fort Collins. CO 80526
Phone 970416-2740 Fax 970-224-6134
CERTIFICATION OF MINERAL ESTATE OWNER NOTIFICATION
PROJECT NAME: fy-) w-- k ` irlLriS; -C Ct_n te-r P f,-) P
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 Development. CITY OF FORT CO NS, OLORADO
Applicant's Signature: By �� Date:
Darin Atte erry, i anager
State of Colorado )
) ss.
County of �ilm' )
cknowledged before me this is day of , 20 LU by
Witness my hand and offici I seal
%ppro T Form
Notary Public
sslsi . t ty Attorney
My commission expires: t (a _ � o lv
NOTARY
N'; PUBLIC