Columbine Lake Country Club, Inc.

P. O. Box 714

Grand Lake, Colorado 80447

Telephone: (970) 627-8120                     Fax: (970) 627-3313

Building Request, Checklist and Permit

Exhibit J

(For Fire Pit)

THIS FORM MUST BE COMPLETED, SIGNED BY LOT OWNER, AND APPROVED BY COLUMBINE LAKE COUNTRY CLUB, INC., BEFORE YOUR FIRE PIT PROJECT HAS COMMENCED.  BEFORE PROCEEDING, IT IS EXTREMELY IMPORTANT TO REVIEW AND UNDERSTAND THE "DECLARATION OF PROTECTIVE COVENANTS, RESTRICTIONS, EASEMENTS, AND RESERVATIONS, COLUMBINE LAKE SUBDIVISION", THE "COLUMBINE LAKE COUNTRY CLUB, INC. BUILDING CRITERIA AND INFORMATION", AND THE INFORMATION CONTAINED IN THIS APPLICATION.  GENERAL INFORMATION AND IMPORTANT NOTES ARE WITHIN THIS FORM.

1. Owner___________________________________________________________________________

2.  Mailing Address__________________________________________________________________

3.  Phone Numbers: (Home) _____________________ (Work) ________________________________

                                  (Grand Lake)______________________ (Fax) ____________________________

4.  Columbine Lake Property: Block No. ________ Lot No. _________Email: ___________________

     Street Address____________________________________________________________________

5. Builder or Contractor___________________________Company____________________________

     MailingAddress___________________________________________________________________

     Phone: _____________________________Fax: _________________________________________

6.  Start Date (Proposed): __________________________________________________

__________________________________________________________________________________

For Office Use Only

 Date received from Owner: __________________________________________________________

 Date Approved___________________________ Date Permit Issued_________________________

Check Info:  Amount ___N/A__________ Number _____N/A______ Date Deposited ____N/A____

Date of Disapproval: _________________________________________________________________

Date of Mailing Notice of Disapproval __________________________________________________

Fire Pit Specifications

1. I desire to build the following fire pit on my property in Columbine Lake Country Club, Inc.
1. Diameter: _____________________________ (the inside cannot exceed 3’)
2. Depth: __________________________________(No less than 2’ below the rim)
3. Materials: ______________________________________ Fire ring must be twelve inches (12”) above ground level. Any rocks used for fire pit must be no less than twelve inches (12") in diameter. Metal rings are acceptable.
4. Location: ________________________________ (Fire pit must be ten feet (10') from all overhead trees and limbs, and there must be a ten foot (10') area cleaned around fire pit.) A plot plan must be submitted showing fire pit in relation to house, garage, trees, etc.)
5. Water Supply: ___________________ (must be accessible to fire pit via hose, spigot, etc.)
2. No Deposit required.
3. Remember:  Fires must be attended at all times by an adult.
4. Please submit  this form to:

Columbine Lake Country Club, Inc.

Architectural Review Committee

P. O. Box 714

Grand Lake, CO  80447

5.  General Information

a. You will be notified within 30 days after receipt of this information if your plans have been approved or disapproved.

             b. Project must be completed 90 days from issuance of Columbine Lake Country Club, Inc. building permit

c. The sale of your property will transfer to the new owner the obligations of the building covenants and restrictions, and therefore should be considered as conditions to the right to build/sell/purchase at Columbine Lake.

CERTIFICATION

I hereby certify that I have examined and completed this application, and know the information I have given to be true and correct.  I further certify that I have read and understand the Columbine Lake Country Club, Inc. Building Criteria and Information and the Declaration of Protective Covenants, Restrictions, Easements, and Reservations of Columbine Lake Subdivision, and I will comply with all specifications.  I will post the Columbine Lake Building Permit (Columbine Lake Subdivision Architectural Control and Covenant Enforcement Checklist), where they are accessible for check-offs and are visible from the road.

____________________________________________________________________________

Signature of Lot Owner (s)                                                                                Date

DISCLAIMER

Nothing contained in the building application form, process, plans, or approvals should be construed to represent any assurance whatever that the project, as constructed, necessarily complies with any zoning, building code, design review, or other governmental ordinance, resolution, regulation, statute, or requirement.  No Owner may rely upon any approval by the Architectural Review Committee as an assurance of compliance with the foregoing.  Further, the owner is advised that any review by the Architectural Review Committee is for architectural control purposes only.  Nothing in said review process or approval should be construed by the owner or any one acting by or through the owner to constitute a substitution for or replacement of any survey, location certificate, inspection, or other professional review of the construction.

____________________________________________________________________________

Signature of Lot Owner (s)                                                                                Date

Application cannot be processed unless the above certification and disclaimer have been properly signed.