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APPLICATION -SAN REVISI�ONS OCOUNTYoF MMUNITY APPROVoED PMENT ADCTRONS <br /> Name: QI Il <br /> TMENT <br /> 7 <br /> Address! <br /> I Address: <br /> P O• I 2" <br /> S i-o C 5 1 - 3 /r C `j5 5j - ICO2 <br /> Phone: 41(0 4 - 3 39 Phone: C I I�O 4 4 - 33 I q <br /> a <br /> iLY .'}�'^Y4 <br /> T✓> •a 25�" OPar Y condldoNs ofA oval 15 <br /> Revision to:T" k Ms X-94-j <br /> Foe No• E V <br /> Ml EP-84-10 Aki uctm Ex No- <br /> t. Descrt n of ed Rwtsions: <br /> � h <br /> 2. state the rads shows the changes in cl=. mstances which make the sub i ct conditions no longer aro Nate or necaasa <br /> lease Il <br /> 10 <br /> E, T� � f ?�rV,: riffs>, <br /> hew; . 6# �s �. RGIcI r MAYrt IkE Nz<IP,RI ICtkT10N r <br /> ONL1FElbEll?lttlt�. IQTY.flR' TFQ . <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 /> tib Legal property owner(owner Includes partner,trustee,trustor,or corporate officer)of the <br /> property(s)Involved In this application,or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's <br /> Involved In this application and have been authorized to file on their behalf.,and that the <br /> foregoing application statements are true and correct. <br /> � I <br /> Print Name: � m , -- •--• net.. <br /> DfHH _ Signature: <br /> Print Name: <br /> .:...,....- - _ ^aen.y..✓ ,—. ._ Date: <br /> Print Name- Signature: fie• <br /> Print Name: Signature: Date• <br /> '2- <br />