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APPLICATION - LOT LINE ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> .. FILE NUMBER: <br /> ' s <br /> ��AT <br /> I4 ICfif TUT I <br /> Vs <br /> .. z,,t`- fid ? <br /> ONLY THE OWMER QF tlE PR( P,ERTY,OR,!#N'.AEJTHQRtt? AGENT MAl( FILE:AN APi'L.iCATIQN <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 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 /> 1 <br /> ❑ Legalagent ent (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 /> I are true and correct. <br /> Print Name: Signature J Date: ! !DLA <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> 1 <br /> Print Name: Signature: Date: <br /> i <br /> l <br />} <br /> 1 <br /> ROEVSVOPlanning Application Formsl Page 5 of 7 <br /> Lot Line Adjustment.doc.(Revised 6-4-04) <br />