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APPLICATION - SITE APPROVAL <br /> AUTHORIZATION SIGNATURi S <br /> ONLY THE OWNERIOF,THE M61i UTHORIZED AGENT MAY FILE AN APPLICATION. <br /> a <br /> 1, the Owner/Agent agree, to defend,Indemnify,and hold harmless the -lounty 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 /> 0 Legal property owner(owner includes partner, trustee, trustor, or corporate officer) of the property(s) <br /> Involved In this application, or <br /> O Legal agent(attach proof of the'owner's consent to the applicatior, of the property's Involved in this, <br /> application and have been authorized to flie'on their behalf., and that the foregoing application statements <br /> are true and correct <br /> 1 ' /o <br /> Print Name: i.. /n /�iaature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: - --- Signature: Date: <br /> Print Nemec - .....,__.,...,,.»,..._... .: . aignetuni DOW <br /> , <br /> y <br /> ...yA. i- <br /> Ebe+.np. 'b!1 <br />