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APPLICATION LOT: LINE ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT"DEPARTMENT <br /> . c�• iP FILE NUMBER: <br /> 4 AUTHORIZATION'SIGNATURESt's�� <br /> V: 4, <br /> ONLY THE:OWNER-OF THE PROPERTY OR.;AN AUTHORIIZED'AGENT MAY,,F1LE`AN APPLICATION.: <br />' I, 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 /> 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 proof of the owner's consent to the application of the property's involved in this <br /> application and have been authorized to file on their behalf., and that the foregoing application statements <br />(( are true and correct. <br /> I • <br /> Print Name: Yt )Mr&f K LA-+1es_- Signature: Date. <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> 1 Print Name: Signature: Date: <br /> I <br /> RInr=Vsvc\Ptann1ng Application Forms1 Page 5 of 7 <br /> Lot Line Adjustment.doo.(Revised 05-11-09) <br />