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i T <br /> APPLICATION - MINOR SUBDIVISION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NO: MS- <br /> 4�1fioR� <br /> AUTHORIZATION51GNAT, <br /> URES <br /> ^_ONLY THE OWNER OF THE PROPERTYY ORAN°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 employees from any claim, <br /> action or proceeding against the Owner/Agent's project. <br /> 1 further certify, under penalty of perjury,that I am(check one): <br /> 14 Legal property owner(owner includes partner,trustee,grantor,or corporate officer)of theroe s p p rtyO involved in this <br /> application,or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and have been <br /> authorized to file on their behalf.,and that the foregoing application statements are true and correct. <br /> Print Name: c- Signature: Date: <br /> Print Name: Signature: e4 Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> I <br /> 4 <br /> F:IDEVSVSTlanning Application FonnsWinorSubdivision(Rev.12-09-04) Page 7 of 9 <br />