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" ANJPLICATION - LOT LI <br /> a . -- E ADJUSTMENT <br /> FILE NUMBER: <br /> '.. .4:AUTMO.R!ZATION Sl6NAT RE3 <br /> ONLY THE OWNER OF THE 0900ERT1-01tANAIN-O' MAY ME AN APPLICATION. <br /> I, the Owner/Agent-Wee, to defe 4 bdemnik and hold harmless the County and Its agents, officers and employees <br /> from any claim,acdbn or proceeft aQalnst the Owner/Agent`s projecL <br /> I,further,certify under penalty of perjury that I am(check one): <br /> Legal property owner(owner Includes partner,trustee, trustor,or corporate officer of theproperty(s) <br /> app�on. ) involved in this <br /> ❑ Leo agent(attach proof of the owner's consent to the application of the properVe Involved in this application and <br /> have been authorized to Elle on their behalf.,and that the foregoing aPPIketlon statements are true and correct. <br /> Print Name' Signature: , <br /> Date i r <br /> NO Name: Signature: tate: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Nam 5 nature• Date: <br />