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' % \ AePLICATiON - LOT LCE ADJUSTMENT <br /> \1 l/IAAI 11\I Plll fl IT/!'•r%.m\ k 1I, T 1"YTl[1 r11 ADMIT Illy FlA flT1 A�[1T <br /> FILE NUMBER: <br /> _ I <br /> n ALITHORIZAMN. GNAT , RE <br /> - r <br /> ONLY THE.OW-OW -OP THE PROPERTY-OR.AKA-UTHORIZED AGEWT-MAY F.NLE A-N APPL-lCA_TtON. <br /> T;t±a wr er�R Rr�±agree, to"dater ,'iricNemr frf ,'an r'I�efsi"Darr+�tesstlie-C6—anty'eirzdifts'=a t,§; officers acid <br /> employees from any claim, action or proceeding against the Owner/Agent's project. <br /> l,.further, certify.under.penalty.of.perjury:that 1_am.'(chewk one): �I <br /> ii e/Legal property owner(owner includes partner,.trustee,.trustor..or corporate officer).of the property(s). II . <br /> involved in this application, or <br /> 1 Legal agent (attach proof of the owners consent to the application of the property's involved in this <br /> application and fial4 be-err authorized to file-orTtheir behalf_; and thatth6foregoing application,statements <br /> are true and correct: <br /> n <br /> H Print'Name: !I' Lem'i ',` -Signature: Date: _V:2 C� <br /> Print Name: - �� SignatureL�.PZ /. Y r Date: <br /> Print Name: Signature: Date: <br /> l�-Print-Name: Signature: Date: <br /> Print-Name: Signature: <br /> Date. <br /> I <br /> I <br /> i <br />