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.rte <br /> ` � <br /> 41 <br /> At-`PLICATION - LOT L ivE ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> .-FILE NUMBER: . <br /> ' s t, pB 3 <br /> f` <br /> ONLY THE OW1 ER;OF,TH PROPERTY QF AN gUTHOR�ZED A°GENT JCA/ X FItE ptV ipppL�CATD ., <br /> 4r <br /> I, the Owner/Agent agree, to 'defencf, indemnify; and hold harmless the County and its agents, offcers and <br /> q. <br /> employees from any claim, action ar proceeding against the 0A i'r Agent's project. <br /> I, furth , certify under penalty of perjury that I am {check one}: <br /> Legal property owner (owner includes partner, trustee, trustor, or,corporate officer of the <br /> involved in this application, or } property(s) <br /> [�l Legal agent(attach.proof ori the owner's consent to the.application of the property's involved in this <br /> application and have been authorized to file'on their bhalf ., and that the foregoing application statements <br /> are true and correct. - <br /> Print Name: Signature: Date <br /> Print Name: l Signature: <:. _ Date: <br /> Print Name: ] Signature: Dateg4 �"g <br /> Print Name: ! Signature: Date:S GP <br /> Print Name: &f—1 L"01.R,C_ Signature: ■�l Dater -Q <br /> " _ <br /> i <br /> s + <br /> r <br /> F;IDEVSVCSPlanning Application Formsl Page 5 of 7 <br /> Lot Line Adjustment,dm.(Revised 6-3-03) <br /> r <br />