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APPLICATION - LOT LINE ADJUSTMENT <br /> 2 • <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> �`'•• ''°' FILE NUMBER: <br /> tiW0 <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> 1, 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 /> 1, 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 /> Print Name: 491— iaaiL Signature: <br /> -E Rate: <br /> � ( <br /> Print Name: c?CVV Ge t .r <br /> �� NJ ure: Date:,— �,Log <br /> Print Name: /A2 Q^J& cto�nature: Date: <br /> Print Name: Signature: Date: <br /> Print Name; Signature: Dater <br /> I <br /> i <br /> FADEVSMPlanning Applicauon FOFMs5 Page 5 of 7 <br /> Lot Line Adjusiment.doc.(Revised 6-4-04) <br />