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I� flW + 6NE <br /> APPLICATION - LOT ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> •.. .P FILE NUMBER: <br /> �iKotz`�' <br /> AUTHORI�ATQN SfGNATURE$ <br /> ONLY THE QWNER:O,F THE PROPERTY.ORAN:AUTHORIZED AGENT MOTIf`E_AN�APPLICATION <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 County arising from the Owner/Agent's project. <br /> I, further, certify under penalty of perjury that l am (check one): <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 <br /> are �I/}/true and correct. <br /> 011 <br /> Print Name., ��4/Sd,J cl/9. s Signature: Date: 9 9//0 <br /> Print Dame: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date- <br /> M <br /> F:IDEVSVC\Planning Application Forms\ Page 5 of 7 <br /> Lot Line Adjustment.doe.(Revised 05-11-09) <br />