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T rAPPLICATION - LOT LINE ADJUSTMENT <br /> � o- �" <br /> �I�I� SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> •�` .P;• FILE NUMBER: <br /> ;; AUTHORIZA"��ON SI+`GN�4TU�I��S� 4 <br /> 3 T <br /> ONLY THE OWNEROF TF�E':PROPERTYR,AN,AUTHORZED.A6NT,,,tVIAY,FILE gN AP.PLtCATION <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 /> [Legal property owner (owner includes partner, trustee, trustor, or corporate officer) of thero ert s) <br /> involved in this application, or <br /> P P Y( <br /> ❑ regal 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 /> f <br /> Print Name: M SC5 Signature: AA _. Date: L! - �`j <br /> Print Name: C�C.1SG�� Signature: 1 . / Date: <br /> Print Name: G� }Fj�j Signature: Date: �? <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date; <br /> - <br /> F <br /> 9 <br /> F\DFVSVC\Planning Application Forms\ Page 5 of 7 <br /> Lot Line Adjustment.doc-(Revised 0-3-03) <br />