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T LINE ADJUSTMENT <br /> V e SAN JOA UIN C uNTY cummuy TY DEVELOPMENT DEPARTMENT <br /> a T RrxArr ' NaT RE <br /> - Q=r1415 OWKM OF THE PROMa 0 Ahl-A-UTHORIZED AGENT MAY FILE jgj2 APPLICA <br /> to the Owr?erfAgent agree,to defend,lndemnlfy,and hold harries the County and Its agents,officers and employees from any claim,action or <br /> nroceeding against the Owner/Agent's project <br /> i,further, certify under penalty of perjury that 1 am(check one): <br /> O Legal property owner(owner Includes partner,trustee,grantor,or corporate officer)of the property(s)Involved In <br /> this application,or <br /> O Legal agent(attach proof of fhe 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: Signature: <br /> Print Name: `Si ature: Dater"/o-,"'6,4 <br /> Print Name: 1 - Signature: -d� Date: <br /> Print Name: r 5 ��� S� Signature: Date: /D^O7 <br /> Print Name: Signature:' Date: <br /> I <br /> y] <br /> 1 <br /> i <br /> v <br /> I <br /> E <br /> a"c"a+.aer==-+-�+'-• yr' �Y� � r. - w.�� may.. � <br /> I <br /> F,DEV9ER/IDARN/PLANAPPS/LDPLINEADJAPPMPX REV 2/3/99 -4- <br />