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09/01/98 10:37 FAX 3106473079 <br /> MedlaJne <br /> . SEP-01-1958 09:4e rEgIRCNE 10002 <br /> I; 2099579628 P.06 <br /> y APPLICATION - SITE APPROVAL <br /> GIS j <br /> AtJTH4RT1© Sem <br /> rturthe'r. <br /> E� (gent agree,to defend,indemnify,and hold harmless Me County and its agents*officars anderttployerm,action orproceeding agalnsrthe OwneriAgentS projectify under penalty of perjury=hat!am(check one): <br /> Legal Property owner(owner inCludea paftner,trUBtee,trustor,or cerporate oMcef)of the <br /> proP4+ty(9)Involved in this appflcatlon,ar <br /> Lepel <br /> in agenr(amch proof of the ewn4rs ce!!tsanr:re the apP►itaden efthe propersy's Invefved <br /> this rtppf;cation and have bNn autharized to file an their behalf.,and that the foregoing <br /> apPilcatien statements are true and ccrracC <br /> ji <br /> LN4tt-- <br /> Print � Slgtuture; <br /> -Oatc <br /> Name; Signature: _ <br /> ��Signature Oate: <br /> Stgrrature Date, <br /> j <br /> jj <br /> 4 <br /> 4 <br /> I; <br /> , <br /> I' <br /> i? <br /> i <br /> , <br /> !i <br /> 13 <br /> I� <br /> II <br /> s9 <br /> 'i <br /> i <br /> 3j <br /> ii <br /> d <br /> i <br /> i <br /> f <br /> I <br /> F ! <br /> t <br />