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p4UlN tA OPLICATION - LOT L IE ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNTi Y DEVELOPMENT DEPARTMENT <br /> �`'• P FILE NUMBER: <br /> 4� FORr\ -- <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 I am (check one): <br /> t9 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 file on their behalf., and that the foregoing application statements <br /> are true and correct. <br /> =Name: <br /> Signa y ' G Date: ozll <br /> itck--,Ee Ignature: / �LY/ Date: —�! <br /> Print Name: <br /> Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> i <br /> F:\DFVSVCP1anning Application Forms\ Page 5 of 7 <br /> I It I m.AAi-t-t A- IP-A u 4"JIA\ <br />