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�aPg�IN. APPLICATION -- ENTERTAINMENT PERMIT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> i <br /> FILE NUMBER: <br /> Other <br /> Describe any items of historical or archaeological interest onsite e. .cemeteries or structures): <br /> Describe any on-site or off-site sources of noise orvibration ie.ifreeway noise,heavy equipment,etc. : <br /> Describe any on-site or off-site sources of ti ht of glare\ parking lot lighting,or reflective materials used): <br /> Describe any on-site or off-site sourc of o e. .a ricultural wastes): <br /> Describe any displacement of people that will be caused by the project(e.g.numbers of people,housing units): <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> I, the OwnerlAgent agree, to defend, indemnify, and hold harmless the County and its agents, officers and <br /> employees from any claim, action or proceeding against the Owner/Agent's project. <br /> 1,further, certify under penalty of perjury that I am (check one): <br /> XLegal 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 Fife on their behalf., and that the foregoing application statements <br /> are true and correct_ <br /> Print Narne:jQ&d v �rit' Signature: Date: <br /> Print Name: J 't'rg46 r Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FADEVSVOPlanning Application FormslEntertairvnent Permit.doc Page 6 of 10 <br /> (Revised 04-13-04) <br />