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N REVISIONS OROVo D ACTIONS <br /> COUNTY COMMUNITYD <br /> .tx T•.a YR'safs s .. s <br /> �l> R TA FIL�tG THS APPt IGRTI07t <br /> .rq"��pfdttt.�tiBY`THk <br /> h k <br /> F ���� `s'A ticant tttfortnat[oit <br /> iC7 .#a[am Y o <br /> .; �(t(flN ib Name: <br /> Name: p.. G� Address: p <br /> �,.(i( 1 Pit tkl T S 1 <br /> Address: 4 D>< G �= C� CI 573 <br /> CSD N I <br /> q 1 Q <br /> Gym GA <br /> Phone: <br /> 4— � Q• 6 Phone: <br /> :: �M, lis3''/t,..�' 3iE1�s^nYF�L•n..S '7' s.e. 3 ., <br /> CandldoNs of A royal <br /> Ma <br /> Revision to: <br /> File No: <br /> t, Descrl donor roposed Revisions: S �"(-( 1 Q$f011415 <br /> IrJ t.l9 V 11 ( lS C NDIfION N w w Sre )C7,10 l <br /> Eco ri 1 YRI. b SIJTIOWP I r rr� INCS 7D SlJ1t n 6 11 N <br /> uT )!96 tV yg0AMCI All If <br /> 2 State the facts showin the than as In circumstances which make the sub ect condition s no Ion er a to riate or necessa <br /> > Q,C}IET Itd <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY`OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION:' <br /> Owner/Agent agree,to defend, indemnity, and hold harmless <br /> claim,action or proceeding against the owner/Agents e County and its agents, officers and <br /> p oject <br /> ployees from <br /> I,further, certify under penalty of perjury that 1 am (check one): <br /> Igo 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 /> �rZii ft Aviv Signat ea " " <br /> r - oats•: 12 1 1 <br /> Print Name: <br /> ,.. ./-/Pwvv! <br /> Print Name: / :cYn,4 ,��/L.rl�shvt�E�•• .,,�,, ._c nate: %2-210 <br /> ...... �.- <br /> Print Netne: <br /> Signature: Date, - <br /> Print Name' <br /> Signature: Date: <br /> Print Name: <br /> Signature: Date: <br /> -2- <br />