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P-IV i APPLICATION - LOT LINE ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> Y{ �. -...•,•...•-:� FILE NUMBER: <br /> �1FOt2l� <br /> AUTHORizATIQN'SIG NATURES <br /> ONLY THE OWNER OF THE PROPERTY ORAN AUTH - <br /> ORIZED 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 /> I, further, certify under penalty of perjury that i am (check one): <br /> Legal property owner (owner includes partner, trustee, trustor, or corporate officer) of the property(s) <br /> Involved in this application, or <br /> Legal agent attach roof of the owner's consent to the application of theproperty's involved in this <br /> ❑ 9 g ( P pp� <br /> application and have been authorized to file on their behalf., and that the foregoing application statements i <br /> are true and correct. <br /> ��"" L r <br /> Print Name: ke4/4w ,C. !.e Ven hl•.raksignature: Date: . f Z Jd <br /> Print Name: A1,40tV .f• ZQ✓e`tf/-V , ' <br /> Signature: / Date: —/O � <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> I <br /> i <br /> II <br /> RZEVSMplanningApplication Forms\ Page 5 of 7 <br /> Lot Line Adjustment.doc.(Revised 64-04) <br />