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APPLICATION - MINOR SUBDIVISION <br /> • SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NO: MS- <br /> .jsa <br /> A�U ' I0RI171�$iENATUR� <br /> ONLY400 . 1Y PRCjP I �Y 012 A ►�1f4WO ED <br /> :QO FI'MAY�1LE.AN QPPLiGd71Q�V. `x` <br /> I,the Owner/Agent agree,to defend,indemnify,and hold harmless the County and its agents,officers and employees from any claim, <br /> action or proceeding against the OwnedAgsnt's project. <br /> I further`certify,under penalty of perjury,that I am(check one): <br /> Lh Legal property owner(owner includes partner,trustee,grantor,or corporate officer)of the property(s)involved in this <br /> application,or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and have <br /> authorized to file on their behalf.,and that the foregoing application statements are true and correct. been <br /> Print Name: ft Signature: <br /> I <br /> Date:,�l�/0 <br /> I A Print Name: V�J� Signature: 3/ y�O5 <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> I <br /> M <br /> FADEVSVS91anning Application Forms%Mlnor Subdivision(Rev.12-09-04) Page 7 of 9 <br />