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SU/MS (MH) <br /> SAN JOAQUIN COUNTY COMMUNI*EVELOPMENT DEPARTMENT <br /> iikk n a <br /> 'a wv' �MV W�'h�"YY2 <br /> 1, the OwnerlAgent agree, to defend, Indemnify, and hold harmless the County and its agents, officers and employees from any claim, <br /> 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, of <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 Me on their behaln <br /> and that the foregoing application statements are true and correct. <br /> Print Name: /�y �" �orfL— Signature: ` v Date: 4/11:. <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Prinf Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> P19232\office\Submittals7entative Map Application-1)onati.doc y. <br />