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APPLICATION - REoVI�SIEPARTMENT <br /> SAN OoNS OFF APPRUNTY COMMUNITY OVaED PMENT ABCTIONS <br /> � :T,R�i'OBI COMPEEFI°6'BYTHE.APPLtCRNT`>RWORTUFA:@iG'SHBAPP(1CR710N�"e% , `% <br /> paareas: Soo 7u0aR- a_ /✓ Ma.e..: ✓3°e-- <br /> S�G/L7tw Cif/- 1"S—L/2 <br /> Phone: <br /> ' „,, Irl”Mc <br /> 3evlalon r: Ma aonaltloNs elA meal <br /> File No: <br /> 1, Da+crl tlon of m aea Ravl+bn+: ems. /� u/ <br /> 7 ,t t.�aSef �t/b4 <br /> S,T <br /> 3. Star the facts shawina Nathan es in circumstances which make the subject conalea a nom ere re ror rNee+u <br /> c7 1 <br /> 17a+/N <br /> S C //vS ZAL -T---to G L <br /> AUTHORIZATION SIGNATURES <br /> ONLY Tac..OWNER OF ThE PROPERFY OR ANAUTHORI2EB AGENT MAY FELE AN APPLIOA'10N.� <br /> 4 Na QwnerlAgent agree,to defend,Indemnify,and hold harmless ma County and its agents,officers and <br /> employees from any claim,action or proceeding against the OwnerlAgent's protect <br /> I,further, cewfy under penalty of perjury that I am(check one): <br /> Q/ Legal property owner(owner Includes partner,trustee,trustor,or corporate officer)of the <br /> property(s)Involved In this application,or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's <br /> Involved in this application and have been authorized to file an their behalf.,and that the <br /> foregoing application statements are true and correct. <br /> w� i <br /> Print Name: r4 �7u�� U� Signature: late. <br /> Name: data: <br /> Print Name: <br /> Signature: gate: 'I <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> _Z_ <br />