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�av11Y <br /> APPLICATION = LOT LINE ADJUSTMENT <br /> � QUIN COUNTY COM <br /> SAN JOA <br /> f COMMUNITY DEPAR ME f <br /> f +•C•.- � 4 I 6 <br /> FILE NUMf3f` <br /> AUTH'ORfZATON SIGN <br /> ' aTURES <br /> ONLY THE OWNER pF:THE PROPERTY OR.AN AUTHORlZED,AGENT MAY P'lLE AN APPLICATION <br /> I, 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 /> I, further, certify under penalty of perjury that I am (check one): <br /> 6*-egal property owner (owner includes partner, trustee, trustor, or cor orate offic <br /> involved in this application, or p er) of the property(s) <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: l � �3z D�Ej� Signature: �elftv � <br /> Print Name: Date: <br /> ,Igna Date:-2' <br /> Print Name: Si ature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> Prins Name: Signature: <br /> Date! <br /> FADEVSymPlanning Application Forms\ Page 5 of 7 <br /> Lot Line Adjustment.doc.{Revised 6-4-04} <br /> ,i <br /> li <br />