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i <br /> E LOT LINE ADJUSTMENT <br /> Y 5AN JQAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 'E.:- - -.- .... <br /> : <br /> AUTHORlZATIf}N SIGNATURES <br /> ONLY THE OWNER.OF THE PROPERTY OR AN AIlTNORIZED AGENT MAY f?!LE AN APPLICATION.. <br /> 1,the Owner/Agent agree,to defend,Indemnify,and hold harmless the County and its agents,officers and employees from any claim,action <br /> or proceeding against the OwnerlAgent's project <br /> 1,further, certify underpenalty of perjury that I am(check one): <br /> Legal property owner(owner Includes partner, trustee, trustor,or corporate officer)of the property(s)Involved in this <br /> application,or <br /> O Legal agent(attach proof of the owner's consent to the application of the property's Involved In this application and <br /> have been authorized to file on their behalf.,and that the foregoing application statements are true and correct. <br /> Print Name: rd �t+ (J� <br /> Signature: Date: O <br /> Print Name: Signature: _ <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> •4 <br /> ,-Print Name: Signature: <br /> Print Name; Dater <br /> Signature: <br /> "'.r• Date: <br /> i <br /> . . j <br /> i !I <br /> 1:41 PMPkLA$6 Februuy 1,1M <br /> -4- <br />