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pS14l1/y, � . <br /> "APPLICATION - LOT Lllvlc ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> ' 3 AUTHORIZATION SIGNATURES <br /> THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> fONLY <br /> he Owner/Agent agree, to defend, Indemnify, and hold harmless the County and its agents, officers and <br /> mployees from any claim, action or proceeding against the Owner/Agent's project. <br /> I, further, certify under penalty of perjury that 1 am (check one): <br /> Legal property owner(owner includes partner, trustee, trustor, or corporate officer) of the property(s) <br /> Volved 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 Signature: <br /> Print Name: Date: <br /> Signature: Date: <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: i <br /> Date: <br /> Print Name: Signature: <br /> Date: 1 <br /> t <br /> i <br /> k <br /> f <br /> F:I)EVSVCV42rW*V Appi wftn Fours% Page 5 of 7 <br /> Lai Lh-W AdustrMMdV—{Revised 6444) <br />