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APPLICATION -- LOT LINE ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <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 <br /> employees from any claim, action or proceeding against the Owner/Agent's project. <br /> I, further, certify under penalty of perjury that l am (check one): <br /> ❑ Legal propertyowner(owner includes partner, trustee, trustor, or corporate officer) of the property(s) <br /> involved in this application, or <br /> Legal-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 /> Print Name: _ l� Signature;,•' Date: r <br /> Print Name: AAA. a+ Signatu Date: <br /> Print Name:hQ� olare i . Q6k 1 UL. Signature: Date: <br /> Print Name: _ Signature: Date. <br />` Print Name: <br /> .. Signature: <br /> Date: <br /> I <br /> I <br /> F;0EVSVC%ftnnin9 Applkadan Forms{ Page 5 of 7 <br /> LN Line Ad)usbneru.doc.(Revised 64-01) <br />