TOWN OF FIRESTONE
CERTIFICATION OF NOTICE TO MINERAL ESTATE OWNERS
(Pursuant to C.R.S. Section 24-65.5-101 et seq.)
Name of Development Application:_________________________________________________
______________________________________________________________________________
Applicant’s Name:______________________________________________________________
Planning Commission Hearing Date:_____________________
Town Board Hearing Date:_____________________________
The undersigned applicant, ______________________________________, pursuant to
Colorado Revised Statutes (C.R.S.) § 24-65.5-103(4), hereby certifies that notice of the initial
public hearing on the above-referenced development application has been provided by applicant
to the mineral estate owner(s) pursuant to C.R.S. § 24-65.5-103(1), as applicable to this
development application by either certified mail, return receipt requested, or by a nationally
recognized overnight courier. The applicant hereby acknowledges that applicant is responsible
for determining whether notice pursuant to C.R.S. § 24-65.5-101, et seq. is required, for giving
such notice to the mineral estate owner(s) when required, that the applicant must provide this
certification to the Town prior to the Town convening the initial hearing, and that providing this
certification to the Town shall be a condition of approval of the above-referenced application.
Further, the applicant hereby certifies that the application for development is
! not a qualifying surface development as defined by C.R.S. § 24-65.5-102 (5.7); or
! the applicant has completed or will complete the Town of Firestone Certification
with Respect to Qualifying Surface Developments.
Dated this _____ day of _______________________, 20___.
Applicant:____________________________________________
By: ________________________________
Title:_______________________________
ACKNOWLEDGEMENT
STATE OF COLORADO )
)ss
COUNTY OF _____________ )
The above and foregoing signature of ______________________was subscribed and sworn
to before me this ____ day of _______________, 20____.
Witness my hand and official seal.
My commission expires on: ______________
(SEAL) _________________________________
Notary Public
EXHIBIT X
TOWN OF FIRESTONE
CERTIFICATION WITH RESPECT TO QUALIFYING SURFACE DEVELOPMENTS
(Pursuant to C.R.S. Section 24-65.5-103.3)
Name of Development Application:_________________________________________________
______________________________________________________________________________
Applicant’s Name:______________________________________________________________
Planning Commission Hearing Date:_____________________
Town Board Hearing Date:_____________________________
The undersigned applicant, ______________________________________, pursuant to
Colorado Revised Statutes (C.R.S.) § 24-65.5-103.3, hereby certifies as follows (check only one
applicable section):
! No mineral estate owner has entered an appearance or filed an objection to the
proposed application for development within thirty days after the initial public hearing on the
application.
! The applicant and any mineral estate owners who have filed an objection to the
proposed application for development or have otherwise filed an entry of appearance in the
initial public hearing regarding such application no later than thirty days following the initial
public hearing on the application have executed a surface use agreement related to the property
included in the application for development, the provisions of which have been incorporated into
the application for development or are evidenced by a memorandum or otherwise recorded in the
records of the clerk and recorder of the county in which the property is located so as to provide
notice to transferees of the applicant, who shall be bound by such surface use agreements.
! The application for development provides:
(a) Access to mineral operations, surface facilities, flowlines, and
pipelines in support of such operations existing when the final
public hearing on the application for development is held by means
of public roads sufficient to withstand trucks and drilling
equipment or thirty-foot-wide access easements;
(b) An oil and gas operations area and existing wellsite locations in
accordance with section 24-65.5-103.5; and
(c) That the deposit for incremental drilling costs described in CRS
Section 24-65.6-103.7 has been made.
The applicant hereby acknowledges that this certification to the Town shall be a
condition of approval of the above-referenced application.
Dated this _____ day of _______________________, 20___.
EXHIBIT X
Applicant:____________________________________________
By: ________________________________
Title:_______________________________
ACKNOWLEDGEMENT
STATE OF COLORADO )
)ss
COUNTY OF _____________ )
The above and foregoing signature of ______________________was subscribed and sworn
to before me this ____ day of _______________, 20____.
Witness my hand and official seal.
My commission expires on: ______________
(SEAL) _________________________________
Notary Public
11/9/2007 1:01 PM[drd]S:\Firestone\FORMS\MineralOwnerQSDCert.doc
EXHIBIT X
AFFIDAVIT OF MAILING
Neighborhood Meeting
I hereby certify under oath that the attached notice of Neighborhood Meeting for the
project were mailed to all property owners and
homeowners associations, within 300 feet of the Applicant’s property as required by the Town of
Firestone Development Regulations. The attached list of parties notified is hereby certified as
true and complete. The notice of Neighborhood Meeting were mailed, on the following date
by .
Signature
Date
State of Colorado )
) ss.
County of )
Subscribed and sworn before me this day of , 20 , by
.
Notary Public
EXHIBIT X
AFFIDAVIT OF MAILING
Owners of Interest
I hereby certify under oath that the attached notice of Public Hearing were mailed to Owners of
Interest as required by the Town of Firestone Development Regulations. The attached list of
Owners of Interest is hereby certified as true and complete. The notice of Public Hearing and
vicinity map were mailed, via certified mail, on the following date
by .
Signature
Date
State of Colorado )
) ss.
County of )
Subscribed and sworn before me this day of , 20 , by
.
Notary Public
EXHIBIT X
AFFIDAVIT OF MAILING
Referral Agencies
I hereby certify under oath that the required referral information for the
project were mailed to the Referral Agencies as required by the Town of
Firestone Development Regulations. The attached list of referral agencies notified is hereby
certified as true and complete. The referrals were mailed on the following date
by .
Signature
Date
State of Colorado )
) ss.
County of )
Subscribed and sworn before me this day of , 20 , by
.
Notary Public
EXHIBIT X
AFFIDAVIT OF MAILING
Surrounding Property Owners
I hereby certify under oath that the attached notice of Public Hearing were mailed to
Surrounding Property Owners within 300 feet of the outside boundaries of the property
subject to the development application as required by the Town of Firestone Development
Regulations. The attached list of parties notified is hereby certified as true and complete. The
notice of public hearing and vicinity map were mailed, via certified mail, on the following date
by .
Signature
Date
State of Colorado )
) ss.
County of )
Subscribed and sworn before me this day of , 20 , by
.
Notary Public
EXHIBIT X