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• d. y <br /> APPLICATION - LOT LINE ADJUSTMENT <br /> z <br /> N SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> l <br /> FILE NUMBER: <br /> l 1 ' Ea -21_ 5 <br /> i <br /> o � � -�,L <br /> ONLY THE;QIF THE �iQP��7"�n���a H©�1� tt <br /> �3,,�►C���i1" M�4�t[�.�AN.APPtICATION. <br /> WNER Q <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 Owner/Agent's project. <br /> I further, 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 /> Print Name: Nell Cornell Signature: /'C .Q e,-A7 o�p/ Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FADEVSMPlanning Application Forms\ Page 3 of 3 Job No 2005-180 <br /> Lot Une Adjustment.doc, (Revised 6-4-04) <br />