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Boulder County Land Use Department

Intake Stamp

Courthouse Annex Building

2045 13th Street • PO Box 471

Boulder, Colorado 80302

Phone: 303-441-3930 • Fax: 303-441-4856

Email:

Office Hours: Monday — Friday 8:00 AM to 4:30 PM

Docket#:

Applicant’s Certificate of Compliance

With Article 65.5 of Title 24, Colorado Revised Statutes (H.B. 01-1088, Effective July 1, 2001).

Note to Applicant & Land Use Department:

This form must be completed for any application for development under the Boulder County Land Use Code which (1)

requires a public hearing before the Planning Commission or Board of County Commissioners, and which (2) is either (a)

any kind of planned unit development, subdivision, or resubdivision/replat sketch plan, preliminary plan, or final plat

application, or (b) an application for any other type of Land Use Code approval which anticipates new surface

development (“a Subject Application”).

The Applicant must complete the following certification as a prerequisite to the Land Use Department accepting as

complete any Subject Application which is tendered for processing to the Land Use Department on or after July 1,

2001. [Applicants for an approval of an application such as Site Plan Review, which is granted administratively and

may not require a public hearing, do not need to complete the following certifications unless and until their

application is appealed to or called up for a public hearing]:

I, _________________________________________, Applicant for the following named development under the

Boulder County Land Use Code _____________________ (Docket # ____________________) (“the proposed

Development”), hereby certify that I or my agent have examined the records in the Office of the Boulder County Clerk

and Recorder to determine if any owners or lessees of any severed mineral estate in the property which is the subject

of the Proposed Development (“the Subject Property”) (i.e., owners or lessees of mineral rights constituting less than

full fee title in the Subject Property) can be identified, as required by Article 65.5 of Title 24, Colorado Revised Statutes

(also known as “H.B. 01-1088”(“the Act”)). Further, based on this examination, I have determined that (check

applicable entry):

No such mineral estate owners or lessees exist in the Subject Property.

Mineral estate owners or lessees exist in the Subject Property to whom notice of the County’s initial public

hearing on my application will need to be sent as required by the Act.

Certification:

I certify that the information and exhibits I have submitted are true and correct to the best of my knowledge.

Applicant Signature:

Applicant Name:

Date:

Applicant Signature:

Applicant Name:

Date:

Note: The same person(s) signing the development/docket application form on behalf of the Applicant must also sign

the foregoing certification.

Form: P/19 • Rev. 10.06.08 • g:/publications/planning/P41ComplianceCertificateForm.pdf

Form P/19 - Applicant''S Certificate Of Compliance - Boulder County Land Use Department