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Pqutr� <br /> APPLICATION - MINOR SUBDIVISION <br /> Z <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NO: MS- <br /> c•._ �P <br /> ���FORa <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 employees from any claim, <br /> 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,grantor, or corporate officer)of the property(s)involved in this <br /> application,or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and have been <br /> authorized to file on their behalf.,and that the foregoing application statements are true and correct. <br /> Print Name: An t lAna U J , !)Uf 66l. Signature: �Cl'� ( /i' " Date: Jr— <br /> y, // - J <br /> Print Name: _}�Q+1 IC�iCx- 1� �Uf Ila- Signature: f/I,C 'Ll �/� ,Cfl�//�//� ) Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F.\DEVSVS\Planning Application Forms\Minor Subdivision(Rev. 12-09-04) Page 7 of 9 <br />