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i <br /> yL <br /> r <br /> APPLICATION -- LOT LINE ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> Nw <br /> taik g � rl-fBFi` EC3'S�C�I / UR'E$ <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION <br /> 1, 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/Agent's project. <br /> 1, further, certify under penalty of perjury that I am (check one): <br /> ❑ Legal property owners (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 /> Print Name: <br /> SignatDate-A) �114> <br /> Print Name: Si nat <br /> Date: <br /> Print Name: Sin Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> 4 <br /> F:IDEVSVC\Planning Application Forms\) Page 5 of 7 <br /> Lot Line Adjustment.doc {Revised 6-04-04 <br />