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APPLICATION - LOT LINE ADJUSTMENT <br /> ' SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> s:AUTHORIZATION ;SIGNATURES"t q <br /> .°.�. .R 'Gtr, .7i`MV �, Ssf ,.: 9wl�til'.y.��.� <br /> ONLY THE OWNER<OF THS PROPERTY.ORAN AUTHORIZED.AO3ENT MAY.FIL.E.'AN APPU0AT16N. <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, further, certify 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 file on their behalf., and that the foregoing application statements <br /> are true and correct. <br /> Print Name: ± Y� (..c+•�, Signaturg Date:� -` ��_ <br /> Print Name: Signatur �' Date: <br /> i <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: ! <br /> 1 <br /> wi vsrrcv+a► ano+,Fom�s1 Page 5 of 7 i <br /> t o!ane Mu&—t d-t W1Wd saoa) <br />