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ALICATION - LOT LI' E ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> c . FILE NUMBER: <br /> E <br /> _ _.. <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: CAROLE SLETTEN Signature: Date: Wc", <br /> Print Name. Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br />€ print Name: Signature: Date: <br /> i <br /> i <br /> i <br /> I <br /> IA <br /> MEMC1PfanningApplicalion Formsl Page 5 Of 7 <br /> of Line Adjustmentdoc.(Revised 64-04) <br /> I <br />