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USE PER►, <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTML <br /> - 0 sM"m RUIR11 <br /> AU.TFJO GNA RE <br /> ?', k :': +. .....i'xi."�t+. ' : , .'�t�`ttrTikr' 'K . . <br /> ONLY THE OWNER OF THE PROPERTYOR AN AUTHORIZED AGENT MAY FILEAN'APPOCATION. 4 <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 /> i <br /> K Legal property owner(owner includes partner, trustee, trustor, or corporate <br /> officer) of the property(s) involved in this application, or <br /> o Legal agent(attach proof of the owner's consent to the application of the <br /> property's involved in this application and have been authorized to file on their <br /> behalf., and that the foregoing application statements are true and correct. <br /> i I <br /> Print Name: Y fgcl� MrNATRE Signature: Date: l e1 <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br />