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q, 4��►y,x t <br /> APPLICATION - LOT LIN# t'. ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> ���`1T[ RlZATIQN :SIGNATURES <br /> '.l'ri 'r fd4`1 ' rah ;{t <br /> ONLY 7H OWNER 0�°THE PROPERTY QR AN'AUTHORIZED`AGENT.MAY FILE:AN APPLECATION. <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 /> 1,>furthn_e rtify under penalty of perjury that I 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 /> ❑ 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 fife on their behalf., and that the foregoing application statements <br /> are trine/and correct. f <br /> Print Name: 40.�in[L rQ, ,CArt� Slgnat re: ���� Date: / 1... —11 —o 27 <br /> Print Name:Q Al y �J r�c rl Yl Signature: pate: I1 0'7 <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> i <br /> FiDEVSYCIPtamiry ApOcOm F4rtrn1 Page 5 of 7 <br /> Lac uke A d=(11W+Ged 64 4) <br />