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" APPLICA ? - SITE 4PPR61VAL <br /> A 1 r-WRI IT1( N <br /> <Olf!'LYTHagh�iVR�QF `HE.PRC?PRT�.QR.eANl4iJfNORIZp. (3EllITM�A'► F1iAN APFI.IAlQlli <br /> 1, 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 Owner/Agent's project <br /> 1, further, certify under penalty of perjury that I am(check ane): <br /> ❑ Legal property owner(owner Includes partner, trustee, trustor, or corporate officer) of the property(s) <br /> Involved in this application, or <br /> ❑ . Legal agent(attach proof of the owner's consent to the application of the property's involved In this <br /> application and have been authorized to file on their behalf.,and that the foregoing application statements are . <br /> true and correct <br /> Print Name: Signature: Date:Ar <br /> Print Name: _ Signature: Date. <br /> Print Name: Signature: Date. <br /> Print Name: Signature: - Date: <br /> Print!dame: Signature: Date: <br /> r . <br /> i . <br /> I � <br /> r <br />