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<br /> APPLICATION - REVISIONS OF APPROVED ACTIONS "
<br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT
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<br /> Flame: !� ` O J� b Name: L ti A_IV o
<br /> Address: o� J t'Iflrpet Address: AlAR4 rrA
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<br /> Phone: �d'3�o Phone:-- L 6 - y 7 - T31-.0�pc
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<br /> Revision to: /"l Map 0_7 Conditiords of Approval
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<br /> t. Description of proposed Revisions:
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<br /> 2. State the facts VMYfM the changes in circumstances which make the subject condition s�no longer a
<br /> oon era mo 'ate or .
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<br /> .:,: ........:A FOR tT Q $ C RES
<br /> t NI_'F 'HE QSNNEi�QF:THEPI aPERT' QI A HaRt ED:RGFNFT:MAY PLI ltl.kF.W11]I�
<br /> I, the Owner/Agent agree,to defend, indemnify,and hold harmless the County and its agents, officers and
<br /> employees from any claim,action or proceeding against the OwnedAgent's project.
<br /> 1,further, certify under penalty of perjury that I am(check one): _
<br /> Legal property owner(owner includes partner, trustee,trustor,or corporateoffiver)of the
<br /> property(s) involved in this application,or w
<br /> 0 " Legal agent(attach proof of the owner's consent to the application of the property's
<br /> involved in this application and have been authorized to file on their behalf..and that the
<br /> foregoing application statements are true and correct
<br /> Print Name: T�]ZZG Signature:
<br />� Print Name• � �............4- ..�e•- -- - _ _
<br /> Print Name: Signature: Date: _
<br /> Print Name: Signature- J Y ' Date:
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<br /> Print Flame: 'Signature: Date:
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