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Y 7A_ PPLAT - USE PES .` <br /> smjoAdul'WCOUNT FCOMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: UP= w <br /> '-- ,VUher ... <br /> Describean itemssof histbriearor archaeoio lcai,interes"ton-site e -ceineteries=or.structures <br /> s <br /> Describe ori orr-site oroff-site sources of'naise orvibratiarr e: .freewa noise heavy a ui menta:etc <br /> Describe any on-siteor off-site sources of light of glare e.g_parkin lot lighting,or reflective materials used <br /> lam► AY?e� <br /> Describe any on-site or off-site source of odor(e.g.agricultural wastes : <br /> D Describe any displacement of people.that wiU be caused by the Rroject(e.g.numbers of people,housing units): <br /> ani <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 agents, officers and <br /> employees from any claim, action or proceeding.against the Owner/Agent's project. <br /> I, further, certify under penalty of perjury that'l 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 /> ❑. Legai 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 Mf3'YAKIM&DY] iNi4ll Signature: Date: �✓' �" <br /> :.Print Name Signature: Date:. <br /> Print Name: Signature: Date: <br /> P <br /> PrintName: Signature: Date-. f <br /> Pririt Name: Signature- Date: <br /> F.-DEVSVMPlanning ApplitaWn Formsluse Permit.(Revised 1-2.03) Page Jr of 9 <br />