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LOT LINE ADJUS M MNN <br /> Sp A IN CO NTY C MMUNfTY DEVJ=LOPM <br /> E <br /> 1211211:''If 1116 1!Ell,E 111i, 19 11212111 <br /> [t 11:: III1101115i <br /> ner/A ent agree, to defend,indemnify,and hold harmAUTH <br /> less the County and Its agents, officers and employees from any claim,action or <br /> 1,the Ow 9 <br /> proceeding against the Owner/Agent's project. <br /> i <br /> 1, further, certify under penalty of perjury that I am(check one): p s Involved 1n <br /> Legal property owner(owner includes partner,trustee,grantor,or corporate officer of the property(s) <br /> this application,or <br /> O Legal agent(attach proof of the ownel's consent to the application of the property's Involved In this application and <br /> have been authorized to Rte on their behalf.,and that the foregoing application statements are true and correct. <br /> ,�} >> Date: <br /> Print Name: ka r + " G' 6 u r Signature: <br /> M <br /> Date: <br /> Signature: <br /> Print Name: Date: <br /> Print Name: <br /> Signature: <br /> Signature: <br /> Date: <br /> Print Name: <br /> Date: <br /> Print Name: <br /> Signature: <br />{ <br /> i <br /> a <br /> F <br /> F <br /> nw;vsee/innun/r�.nx�a,ra/Fuxin er�iNei•rraw4+sry x/1/•�e -,y_ <br />