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APPLICA�ION - REVISIONS OF APPROVED ACTIONS <br /> w: <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> < <br /> •�42iFonN FILE NUMBER: - <br /> WOW) <br /> r <br /> t <br /> TO BE COMPIJETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Infonnatio i Applicant Information <br /> Name: _ - - Name: <br /> Address: <br /> I ' Address: <br /> Phone: Phone: <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: r Map Conditions)of Approval <br /> File No: <br /> 1. Description of the proposed Rev ions: <br /> 2. State the facts showing the cha ges in circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> ri 1 <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 defer, 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 /> ❑ Legal property owner(owner inbludes partner, trustee, grantor, or corporate officer)of the property(s) involved in <br /> this application, or <br /> ❑ Legal agent(attach proof of thef'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 statements are true and correct <br /> Print Name:- ...,`/ /;F ' ✓%,CL Signature: j I -mak/ "Z44,r1" ar<ir'Z Date: %?_ Z_; i't <br /> Print Name: IL21,0, - --Signature:-,N/ �Luy`:Lu-(/� Date: <br /> Print Name: J <br /> j Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: i S' nature: Date: <br /> F:IDEVSMPlanning Application Forms%Revisiom of 14pproved Actlons.doc Page 2 of 2 <br /> (Revised 05-11-09) [[ <br /> x <br /> 6 <br />