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w <br /> u:~ appl ICATION LOT_ !INE ADJUS <br /> �"�ME ' <br /> c _ L <br /> s2lV�Ji3!la.Fi:l EES lJ0..f!!!\!E LlJ��€f€9ER.{ E.FLK .0.1�(gF t=f Cµff[�thFF E l8fg } <br /> e ^^r <br /> OILY.' Hf QitIaNER ml`. 'H #tflF1E= : ? � �..�.� ...,.- . . - . <br /> I, the Owner/Agent agree, to defend, indemnify, a .fid the.minty.arid its agents, offic -anti <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(€tock one): <br /> Vr Legal'property owner(owner includes partner,trustee;trustor,or corporate�)of the s <br /> involved in this application, a= ) <br /> El 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 awn statementsare true and correct, <br /> Print Name: 0 n Signature: <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br />'U)r=VSVCIPIanning Appfice ion Forms! Page rJ of 7 <br />.ot Line Adustmentd=(Revised 5-3.03) <br />