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f <br /> APPLICATION - SITE APPROVAL <br /> _ < ; frt x. t xt r� <br /> u:k Auj.MPI k�TI4N �1 <br /> '4 :# P <br /> isk }xlz . s 4. N <br /> [ . <br /> 77 1 <br /> , IZEDGENT7MAyFjL3Q61�� Pi ;C1 �V ,, „ <br /> 1, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and <br /> t employees from any claim, action or proceeding against the Owner/Agent's,project. <br /> 1, further, certify under penalty of perjury that l am (check one): <br /> O Legal property owner(owner includes partner, trustee, trustor, or corporate officer) of the property(s) <br /> involved in this application, or <br /> !J 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 <br /> are true and correct. <br /> Print Name: Z761�ZMZ2 i/l/W P� Signatur Date: /Q <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> i <br />