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APPLICATION - REVISIONS OF APPROVED ACTIONS <br /> :< SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> '� ,yy Owner Information Applicant Information /I <br /> Name: ( V 1+e;,,— Z e (qF f Name:4 Alfj Ne b � �✓ <br /> Address: ;19 IT-511-x ` Address-,N C/© " ,(Al" <br /> Phone: Phone: <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: Map Condition(s)of Approval <br /> File No: <br /> 1. Description of the proposed Revisions: <br /> Lc g 5 r1- To AC;-p_ IN C t'" <br /> 2. State the facts showing <br /> `the changes in circumstances which make the subject condition(s)no longer appropriate or/n/e^cessary. <br /> ..moi\ �.J l LI O 10 i� � �J � ���I"U i L+1/-��/�1(C)w'�t h li`1 l V`ice' <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE 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 Owner/Agent's project. <br /> I, further, certify under penalty of perjury that I am (check one): <br /> ❑ 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 foreI application statements are true and correct. <br /> Print Name: f�0 �e'r� � l/tee fV- Signature: Date: U <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:\DEVSVC\Planning Application Forms\Revisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 10-19-04) <br />