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UOC rCKiVJ <br /> SAN JOAQUIN COUNTY Cr3MMUNITY DEVELOPMENT DEPARTMF <br /> Q-,R(7J�'�O �SIGIy44`�URES <br /> sus. ...... I'j Q ...., _ •... .. . <br /> OHL _JH .OWNEWOFfliEPROA QR; 11 O �OENTilR1�R JI I1PpF1CAT10 <br /> 1, the Owner/Agent agree, to defend,Indemnify,and hold harmless the County and Its agents, <br /> officers and 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 /> oofRcer eo the �e�owner(owner includes partner, trustee, trustor, or corporate <br /> p p rty(s)involved in this application, or <br /> i <br /> o Legal agent(attach proof of the owners consent to the application of the <br /> Property's involved in this application and have been authorized to rile on their <br /> behalf.,and that the foregoing application statements are true and correct <br /> I <br /> Print Name. <br /> Signature: Date.3 <br /> Print Name: Signature: <br /> Date: <br /> Print Name: <br /> Signature; <br /> Date. <br /> Print Name: Signature: <br /> Date: <br /> Print Name: <br /> r > <br /> Signature: Date. <br /> F <br /> i <br /> 1 <br /> R <br /> p <br /> 1 <br /> i <br /> s <br />