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APPLICATIuN - REVISIONS OF APvROVED ACTIONS <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> ` FILE NUMBER: -PAI� o-l`k <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO,FILING THE APPLICATION <br /> Owner Information Applicant Information <br /> Name: Fa:,t t �-, ' (r;w; Name:TL,,,, 1, — •r l <br /> Address: t22 o Address: <br /> �Phon;2-00t-55D-351t t Phone: <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: PA-C>&,0n3,93 Map Condition(s)of Approval <br /> File No: <br /> 1. Description of the proposed Revisions: ' — i %-- c>r <br /> �rtCAs C-bo <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> AUTHORIZATION SIGNATURES <br /> ONLYTHEOWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MATfILE AN APPLICATION.- <br /> I, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and employees <br /> from any claim, action or proceeding against the County arising from the Owner/Agent's project. <br /> I,further, certify under penalty of perjury that I am (check one): <br /> 21-*,—Legal property owner(owner includes partner, trustee, grantor, or corporate officer)of the property(s) involved in <br /> this application, or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and <br /> have been authorized to file on their behalf., and that the foregoing application state ents are true and correct. <br /> '$ruse A i o <br /> Print Name: FPso FRivcl„)d Gw p L.P. Signature: Date: 111,1122- <br /> Print <br /> 1ty122Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FADEVSVMPlanning Application Forms\Revisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 05-11-09) <br />