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xE <br /> j Sf�f JOAN ii l �iii�i Y € C)GJ'f�rl i IJe Vi OFI\tE DLPAR-€IALNT <br /> ?P <br /> 14IL_L Nl,_1MBFIR: SA- <br /> Other <br /> Describe any items of historical or archaeological interest on-site e. .cemeteries or structures): <br /> Describe any on-site or off-site sources of noise or vibration (e,g.freeway noise, heavy equipment, etc. : <br /> to la,7a i s. 5,2,2,IL-' ? <br /> Describe any on-site or off-site sources of light of glare(e.g. parkinglot lighting, or reflective materials used): <br /> ,v <br /> Describe any on-site or off-site source of odor(e.g. agricultural wastes): <br /> Describe any dis lacement of eeople that will be caused by the project(e.g. numbers of people, ousing units): <br /> AUTHQRIZ�4lV. 11�lATURES.. . <br /> ONLY THE OWNER Old T1FIE PR&ERTY.l7R 4N i4UTFiORIZEE?AGEP17 Mi4Y�fL E AN:APPE: CATION <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 County arising from the Owner/Agent's project. <br /> 1, 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 /> ❑ Legaf agent (attach proof of the owner's consent to the applicatiory of the property's involved in this <br /> application and have been authorized to file on their behalf.,and�hat th foregoing application statements <br /> are true and correct. . <br /> Print Name. G ��c`'� Signature: f , �- Date: <br /> Print Name Signature- Date: <br /> L <br /> Name: Signature: Date: <br /> ame' Signature: Date: <br /> iin,��. Signature- Date: <br /> AA .,- �a">,;=:,, i;:�u lnn Forms';Site Approval.(Revised 05-1 t-M Page 5 of 9 <br />