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APPLICATION - LOT LIFE ADJUSTMENT <br /> SO. .CpG <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> • c..._W.._N,.'P FILE NUMBER: i <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 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 /> 01 <br /> Print Name: rtd'✓N��� /f'���'✓� Signature: /` Date: /� <br /> Print Name: Signature: Date: <br /> Print Name: l%!G'!r a—ez /�'l��✓yf Signature- Date• <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> IE <br /> E <br /> t • <br /> t <br /> F.IDEVSVC\Planning Application Formsl Page 5 of 7 <br /> Lot Line Adjustment.doc.(Revised 6-4-04) <br />