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APPLICATION - REVISIONS OF APPROVED ACTIONS
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<br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT
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<br /> Name:
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<br /> Address:
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<br /> Phone:
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<br /> Conditfonls of A royal
<br /> Ma
<br /> File No: S —(D -
<br /> 1. Descrl tion of ro sed Revialons: S T6R�Gl�
<br /> ILL
<br /> �}�c C
<br /> tach ahowin the chan es In circumstances which make the subject condition s no ion e(a ro riate or necessa
<br /> 2. State the
<br /> ,F►_UTIaAR1ZATiC�N SIGNI�►TURES
<br /> F'UPERTY OR AN AUTHORIZED AGENTRAY FILE AN! APPLICATION h
<br /> ONLYTHE':QWNER OF THE.P ,
<br /> gents,officers and
<br /> I,the Owner/Agent agree,to defend,Indemnify,annold harmless heCos rotect and Its a
<br /> employees from any claim,action or proceeding against the owner/Agent'
<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 the
<br /> property(s)involved In this application,or
<br /> ❑ 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 behalf.,and that the
<br /> foregoing application statements are true and correct.
<br /> �� (�- ,/i.� J
<br /> S U l�oF A-r,,0A L. Signature: �G�'3^�� ----
<br /> Print Name: mate:
<br /> m
<br /> Print Nae: ,{
<br /> Date:
<br /> Print Name: Signature:
<br /> -
<br /> Date: -
<br /> Print Name: Signature:
<br /> Date:
<br /> Print Name: Signature:
<br /> -2-
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