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PA 900
<br /> 1 4
<br /> APPLICATION - REVISIONS OF APPROVED ACTIONS
<br /> o T BONS
<br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT
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<br /> Name: I cK
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<br /> :,.:.... .... MISRevision to :v Conditions of Approval
<br /> File No• 1
<br /> > " ��G✓�men'F
<br /> I• Description of proposed Revisions: 0 11
<br /> C UI<ji /15
<br /> 2• State the facts showing the Chan es In circumstances which make the subject conditions no Ion er a ro riate or necessa
<br /> .AUTHORIZATION SIGNATURES '
<br /> ONLY THE.OWNER OF THE PROPERTY OR AN AUTHORIZEDAGENT MAY:FILE:AN:APPL.ICATION.
<br /> I,the OwnerlAgent 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 1 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 /> Jg( Legal agent(attach proof of the owner's consent to the application of the property's
<br /> Involved In this applicatie 1 and have been authorized to file on their behalf., and that the
<br /> foregoing application statements are true and correct.
<br /> i
<br /> Print Name: LIiko�A5 �� S,ke,t�I S Signature: ..G- �' � �T •
<br /> :
<br /> Print Name:
<br /> Print Name: Signature: Date:
<br /> Print Name: Signature: Date:
<br /> Print Name: Signature: Date:
<br /> -2-
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