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a x �APPLICATION — LOT LINE ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY.DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> 6 f r rL� I'ti f y + v 4ti i t <br /> ,laTNQRIZATION SIGNX ��.URES� �t�; ";. �,�, i � <br /> NLY THE�.+t:1INNF-R.O W.Ro :ER'�1l:, R 4 q YHO Q>�IGENT.MAY.FILE;AN�APPt.I<CAT[ON. -. <br /> I, 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/Agenfs project. <br /> I, further, certify under penalty of perjury that I am (check one): <br /> I <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 /> rD <br /> Print Name Q 67/er,, Signature: Date: - <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Fi0EV6VC%Ranitrg Applratbn Foffi* Page v of 7 <br /> LA W9 A*AWW . =VWvWW 6.4-04) <br /> f <br />