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APPLICATION - LOT LINE ADJUSTMENT <br /> 4 SAN JOAOUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE 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 I 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 true and correct. <br /> Print Name: ig lure: e A 0. Date: <br /> Print Name: n ,/ ZS 11 OiSignature- ._ aite: L4Print Name: IcAymord ord �JF'Ft^1 �F� Signatu <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FADEVSVCwlanrnng Appiim0on Forms\ Page 5 of 7 <br /> L Maf Line Adjas nLd..(Revised 05-11-09) <br />