Form DMM-157 "License Renewal/Transfer Application" - Virginia

What Is Form DMM-157?

This is a legal form that was released by the Virginia Department of Mines, Minerals and Energy - a government authority operating within Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2016;
  • The latest edition provided by the Virginia Department of Mines, Minerals and Energy;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DMM-157 by clicking the link below or browse more documents and templates provided by the Virginia Department of Mines, Minerals and Energy.

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Download Form DMM-157 "License Renewal/Transfer Application" - Virginia

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DIVISION OF MINERAL MINING
900 NATURAL RESOURCES DRIVE, STE 400
CHARLOTTESVILLE, VA 22903
(434) 951-6310
LICENSE RENEWAL/TRANSFER APPLICATION
Application Tracking #
FOR OFFICE USE ONLY
RENEWAL
PERMIT #
TRANSFER
RECEIPT #
DATE ISSUED
Permit No. (Renewals only)
1.
Name of Applicant
2.
Mailing Address
3.
Office Telephone No.
4.
Attach to this License Renewal/Transfer Application the following information on any
contractors who will be working on the mine site in the next 12 months: trade name, business
address, business telephone number, MSHA identification number (if applicable), address of
record (if different than business address), service to be provided, where at the mine the work
will be provided, person(s) with responsibility for operating decisions (name and address) and
person(s) with responsibility for health and safety of employees (name and address). During
the year any contractors on the mine site but not on the list must be reported individually.
Contractors not shown on the attached list will no longer be associated with the mine permit.
PLEASE COMPLETE ANY INFORMATION THAT HAS CHANGED SINCE YOUR ORIGINAL
LICENSE APPLICATION OR SINCE YOUR LAST RENEWAL. IF THE FORM IS BEING
USED TO TRANSFER THE PERMIT, THEN ALL APPROPRIATE INFORMATION MUST BE
PROVIDED.
(be sure to complete the certification statement on page 3, sign and date the form)
5.
Type of Organization:
( )Sole Proprietorship - Complete questions A,B,C,D,E,F,G,I
( )Corporation
- Complete questions A,B,C,D,E,F,G,J,K,L,M,N
( )Partnership
- Complete questions A,B,C,D,E,F,G,H,I
( )Other
- Complete questions A,B,C,D,E,F,G,H,J
Specify:
(A) Mine name, address and telephone number
(B) MSHA ID number of the mine (if applicable)
(C) Person with overall responsibility for operating decisions at the mine
Name/Title
Telephone #
Address
(D) Person to be contacted in the event of an accident or emergency
Name
Telephone #
Address
(E) Person with overall responsibility for health and safety at the mine
Name
Telephone #
Address
(F) Person responsible for business operation of the mine
Name
Telephone #
DMM157
Page 1 of 3
Rev06/16
DIVISION OF MINERAL MINING
900 NATURAL RESOURCES DRIVE, STE 400
CHARLOTTESVILLE, VA 22903
(434) 951-6310
LICENSE RENEWAL/TRANSFER APPLICATION
Application Tracking #
FOR OFFICE USE ONLY
RENEWAL
PERMIT #
TRANSFER
RECEIPT #
DATE ISSUED
Permit No. (Renewals only)
1.
Name of Applicant
2.
Mailing Address
3.
Office Telephone No.
4.
Attach to this License Renewal/Transfer Application the following information on any
contractors who will be working on the mine site in the next 12 months: trade name, business
address, business telephone number, MSHA identification number (if applicable), address of
record (if different than business address), service to be provided, where at the mine the work
will be provided, person(s) with responsibility for operating decisions (name and address) and
person(s) with responsibility for health and safety of employees (name and address). During
the year any contractors on the mine site but not on the list must be reported individually.
Contractors not shown on the attached list will no longer be associated with the mine permit.
PLEASE COMPLETE ANY INFORMATION THAT HAS CHANGED SINCE YOUR ORIGINAL
LICENSE APPLICATION OR SINCE YOUR LAST RENEWAL. IF THE FORM IS BEING
USED TO TRANSFER THE PERMIT, THEN ALL APPROPRIATE INFORMATION MUST BE
PROVIDED.
(be sure to complete the certification statement on page 3, sign and date the form)
5.
Type of Organization:
( )Sole Proprietorship - Complete questions A,B,C,D,E,F,G,I
( )Corporation
- Complete questions A,B,C,D,E,F,G,J,K,L,M,N
( )Partnership
- Complete questions A,B,C,D,E,F,G,H,I
( )Other
- Complete questions A,B,C,D,E,F,G,H,J
Specify:
(A) Mine name, address and telephone number
(B) MSHA ID number of the mine (if applicable)
(C) Person with overall responsibility for operating decisions at the mine
Name/Title
Telephone #
Address
(D) Person to be contacted in the event of an accident or emergency
Name
Telephone #
Address
(E) Person with overall responsibility for health and safety at the mine
Name
Telephone #
Address
(F) Person responsible for business operation of the mine
Name
Telephone #
DMM157
Page 1 of 3
Rev06/16
Address
(G) Applicant's Federal Tax ID Number
(H) List all individuals having any ownership interest in the organization
Name/Title
Telephone #
Address
(I) Trade name, address and telephone number for sole proprietors/partnerships
(J) Principal organization officials, corporate officers, directors and members
Name/Title
Telephone #
Address
(K) Corporation name, address and telephone number if different than applicant
(L) State of Incorporation
(M) Registered Agent
Telephone #
Address
(N) If a subsidiary, provide:
Parent Organization Name
Address
Telephone No.
State of Incorporation
6.
Name, address and telephone number of person(s) authorized to sign Permit/License
Documents.
Name
Address
Telephone #
7.
Have any of the above listed (1) persons, or (2) companies owned, in whole or in part, by said
persons, the applicant, members of the organization, or any person having 20% or greater
ownership interest had a mining permit issued by Virginia or any other state revoked?
(
) Yes
(
) No
If yes, give a brief statement of action.
8.
Have any of the persons listed above been convicted of violating any of the following sections:
45.1-161.292:33, 45.1-161.177, 45.1-161.178, and 45.1-161.233 as related to smoking in
underground coal mines or tampering with methane detection equipment in underground coal
mines?
(
) Yes
(
) No
If yes, give a brief statement of action.
9.
COMPLETE EITHER (A) OR (B)
(A) List all MSHA Federal Identification Numbers issued to the applicant, members of the
organization, or any person having 20% or greater ownership interest in the organization.
Identification No.
Status
DMM157
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Rev06/16
(B) List all names under which the applicant and either members of the applicant or any
person having 20% or greater interest in the applicant operates a mine which has been
issued a MSHA Federal Identification Number.
ONLY TRANSFER APPLICANTS NEED TO COMPLETE #10, #11 AND #12
10. List any mining permits of any type held by the applicant in Virginia and the applicable permit
identification numbers.
Issuing Authority
Permit No./Identification No.
11. List any person with an ownership or leasehold interest in the surface land or minerals to be
mined.
Name
Address
Surface
Surface
Mineral
Mineral
12. Specify source of applicant’s legal right to enter and conduct mining operations on land
covered by the permit:
Provide deed book number, page number, parties to the deed or lease, date of execution or
provide copy of deed or lease.
I,
, hereby certify that to the best of my knowledge, the
(Print Name)
information provided in this License Renewal/Transfer Application is accurate and complete.
Operating Official Signature
Date
DMM157
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