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4 <br /> r <br /> APPLICAI ON — REVISIONS OF At- ?ROVED ACTIONS <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> . FILE NUMBER: }lam D <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Applicant Information <br /> Name: Name: p t/ <br /> Address: Z� i Address:--z--2-1 51 ✓� <br /> 0�ce,1 Ls`"g -Z-0 cr,10/o C-)1) 3�o <br /> Phone: 2�Z>q— R-3 ` tz,�Z Phone: Z — k- <br /> 0 1 <br /> -01 &:2 i v- I ve I or-;I e e • ' `` PROJECT DESCRIPTION <br /> Pro sal <br /> Revision to: Map r Q r Condition(s)of Approval Z <br /> File No: <br /> 1. Description of the proposed Revisions: <br /> ceyylcs ✓ �1 LI <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <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 employees <br /> from any claim, action or proceeding against the County arising from 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)of the property(s) involved in <br /> this application, or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and <br /> have been authorized to tale own their behalf., and that the foregoing application statements are true and correct. <br /> Print Name: IVy���� lT �.�`F- Signature: (2 <br /> Date: <br /> All <br /> Print Name: /1 A i � � K��l� Signature: �• Date: 61 <br /> Print Name: / Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FA)EVSV61Planning Application FormsAevisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 05-11-09) <br />