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<br /> APPLICATION - REVISIONS OF APPROVEr ® ��
<br /> SAN JOAQUIN COUNTY COMMUNITY DEVELO t
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<br /> Name: l IA110. 5 RCV064XIM T11U4TName: �� E���� :r
<br /> R Mourn
<br /> 'Address: 424 IIZAAL Ne 12D. MD17V<1110 Address: AL.UMN XVC
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<br /> Phone: C2o�) 6o�6g6� Phone:
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<br /> Revision to: S/., — Map Condltlonrs of Approval ~M`
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<br /> 1. Description of proposed Revisions:
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<br /> 2. State the facts showing the changes In circumstances which make the subject conditlon s no longer a� ro date or necesaa
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<br /> I,the Owner/Agent agree,to defend,indemnify,and hold harmless the County and its agents;officers iil d,)"�' _ r
<br /> employees from any claim,action or proceeding against the Owner/Agent's project.
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<br /> I,further, certify under penalty of perjurythat I am(check one): a;41
<br /> SIM
<br /> ❑ Legal property owner(owner includes partner,trustee, trustor,or corporate officer)of the o
<br /> property(s)involved In this application,or
<br /> Wl"' Legal agent(attach proof of the owner's consent to the application of the property's
<br /> involved in this application and have been authorized to file on their behaff.,and-that the- '-
<br /> foregoing application statements are true and correct
<br /> Print Name: pOMINILy. G.ULAA Signature:
<br /> Print Name:
<br /> Print Name: Signature: Date:
<br /> Print Name: Signature: Date: v 1
<br /> Print Name: Signature: Date:
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