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APPLICATION - LOT LINE ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> i FILE NUMBER: <br /> . . ------------------- <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 /> William H. Fisk,Trustee of the William H. Fisk 2001 Trust as Ame)nded <br /> Print Name: William H. Fisk,Trustee Signature: ✓•'J�— '� c-,='�ate: _ <br /> Print Name: Martin J. Fisk Signature: 7, / Date: <br /> �i�n� <br /> Print Name: Cynthia A. DeCamara Signature: �` 'L �`�'�' j- 't� Date: 6 —.3 C, ��! <br /> Print Name: Natalie S. Dickman Signature: c�., CtL'rLiGctti; Date: <br /> Print Name: Signature: Date: <br /> FADEVSVCTIanning Application Forms\ Page 3 of 3 Job No 2014-119 LLA 1 <br /> Lot Line Adjustment.doc.(Revised 05-11-09) <br />