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1 T <br /> i <br /> APPLICATION - REVISIONS OF APPROVED" ACTIONS"' <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT s'V <br /> Address: Address: _ <br /> Phone: - - Zia ?hone: <br /> x ' <br /> Revfsion to: t,4I - g7- SS Ma Conditlonls of Aa roval <br /> Re No SA- 977- S - <br /> t, t7escri tion of promsed Revisions: <br /> w V4 v I N T op <br /> Ir <br /> 2• State the facts showing the changes in circumstances which make the sub'ect conditio s no longer aro rfate or necessa <br /> ryi <br /> r <br /> { <br /> :<0NLY:T1.iE•.GWNER.-C)F Pi�QPEi lf.0# Ai E k"I'H4a1�EM-AGENT.1t�E�F1i: Alt1:AtE?Pf1C'Amay <br /> 1. the Owner/Agent agree,to defend, indemnify,and (told harmless the County and its'agents,o_fffcers and � <br /> employees from any claim,action or proceeding against the Owner/Agent's project <br /> I,further, certify under penalty of penury that I am(check one): <br /> j �K 'Legal property owner towner includes partner,trustee, trustor,or corporate officer)of the <br /> ,. property(s) involved in this application,or <br /> I <br /> D Legal agent(attach proof of the owner's consent to the application of the property's <br /> f involved in this application and have been authorized to file on their,behalf.,and that the I , <br /> foregoing application statements are true and correct 1 <br /> Psfn!Name: _ <br /> Signature: <br /> t Print Name: Y?r" '$,).,y f v - <br /> Print Name- Signature: _ pate: T <br /> Print Name: Signature pate: ,1 <br /> s <br /> f Print Name: k Signature: r <br /> Date: ! <br /> v� <br /> r <br />