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APPLICATION - LOT LINE ADJUSTMENT <br /> j : SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <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 /> Harold Van Rys and Susana Van Rys,Trustees of the Van Rys Farlily Revocable Trs .x -1 <br /> f\ ( <br /> Print Name: Harold Van Rys.Trustee Signature: ,.� (VttiJ- ICJ?D(7 <br /> Print Name: Susana Van Rys,Trustee Signature: (� "alja (t$nt Ol2 <br /> ,__ �� Date: -7 �C'j- co).� <br /> Print Name: Mark Genereux Signature: /Zlcwl, � Datepl /c �C/ <br /> �� ���— L <br /> Print Name: Clarisa Genereux Signature: � �'-�� Date:e' r� <br /> F1DEVSVC\Planning Application Forms\ Page 3 of 3 Job No 2017-87 LLA <br /> Lot Line Adjustmentdoc.(Revised 6-4-04) <br />