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n _ SOT LINE ADJUSTMENT <br /> SAN JOAwim COUNTY COMMUNfTYDEVELOPMENT DEPARTMENT <br /> AUTHoRtzArIb S1GNAWRIW. <br /> ONl,Y7#l:CWNI:R C7F T!{E PRQPEFt 1'YOF7 Ak4 AUDI ORIZED AGENT.MAYPILE AN:.ApPLICAi6 <br /> 1,the Owner/Agent agree,to defend,Indemnify,and hold harmless the County and Its agents,officers and employees from any claim,action or <br /> proceeding against the OwnerlAgent's project <br /> I,further, certify under penalty of perjury that l am(check one): <br /> 0 , Legal property owner(owner includes partner,trustee,trustor,or corporate officer)of the property(s)involved in this <br /> application,or <br /> 0 Legal agent(attach proof of the owners consent to the application of the property's involved In this application and have <br /> been authorized to fife on their behalf,and that the foregoing application statements are true and correct <br /> Print Narrte: Rr)(A IE4— ��W P_I"S Signature: I _ Date: <br /> Print Name: 1 Signature: Date: r�[ <br /> Print Name: . AA a Signature: Date: <br /> Print Name. be ,'4- P1r�rSignature: �7�.,c �L ' 1 - d, Date: <br /> Print Name: Signature: ---� � / z b� '' Date: <br /> I <br /> 1 <br /> sa:m wywq.use FeOwrr t.4aee <br />