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APPLICA'T'ION - REVISIONS OF APPROVED ACTIONS <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> i <br /> LIR`OR�`Q FILE NUMBER: - - <br /> TO BE COMPLETED BY'rHE APPLICANT PRIOR TO FILING TW00" .ICA1'i <br /> Owner Information Applicant Information :b <br /> --- - <br /> Name: <br /> .�c—it//1/!.S' AL�X�it/O�/� Name: 4/ � 4/C�i('fic <br /> Address: z'/900 IV Q��j?-/4-- S ,eo Address: 6 -7,6 <br /> Phone: (ZD l� ���8 3/l0� Phone: <br /> - PROJECT DESCRIPTION <br /> Proposal----------- - <br /> Revision to: -p Z 3Z Map It! Q/7-090 -3 Condition(s)of Approval <br /> File No: /� <br /> 1. Description of the proposed Revisions: <br /> '147 SiD2�9 G� <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> G�/LL AL 6 4& �o/Z D2�5 R <br /> D ACI <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 defend, indemnify, and hold harmless the County and its a s, fficers and employees <br /> from any claim, action or proceeding against 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, grantor, or corporate officer o the property(s) involved in <br /> this application, or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the prope 's in Ived in this application and <br /> have been authorized to file on their behalf., and that the foregoing a li atio stateme s are true and correct. <br /> Print Name: TTN�T «X,4 Fi2 Signature: Date: <br /> Print Name: _ Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name. Signature: Date: <br /> Print Name: Signature: Date: <br /> F:\DEVSVC\Planning Application Forms\Revisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 10-19-04) <br />