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a iry fit7PLICATION - LOT L JE ADJUSTMENT <br /> y SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER <br /> t1zo"``y <br /> 15 . <br /> _ S <br /> - 1pi <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: HOWARD KELLER Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> _Print Name: Signature: Date: <br /> Print Name: Signature: Date:_ <br />{ <br /> F <br /> )EVSVG Plannhq Application Formsl Page 5 of 7 <br /> Line Adjustment.doc.(Revised 6-4-04) <br />