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—APPLICATION — REVISIONS OF APPROVED ACTIONS <br /> e" 'fir SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> " FILE NUMBER: <br /> 0 N\ <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Applicant Information <br /> Name: f J, Z 5 Name: E.T Ro f <br /> Address: Address:Po 9DK 3231 <br /> CA -< ' lstor—ki-On Cq 9,5213 <br /> Phone: i1 - l p Phone: aoq- 470 - I q$9 <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: ntGhO QJqltKy Map 0?J o93-q,5b' os Condition(s)of Approval <br /> File No: <br /> 1. Description of the proposed Revisions: <br /> To ex e- d t life- o-F the 't 91 NEall <br /> :It Permit :i#' QX- q1- b <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <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 employees <br /> from any claim, action or proceeding against the County arising from the Owner/Agent's project. <br /> I, further, certify under penalty of perjury that I am (check one): <br /> Legal property owner(owner includes partner, trustee, grantor, or corporate officer) of the property(s) involved in <br /> this application, or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and <br /> have been authorized to file on their behalf., and that the fore in application statements are true and correct. <br /> G <br /> Print Name: E. T. UGIPI Signature: Date: w -.3 1 _ 0 <br /> Print Name: PF-1164L-1164LI/1y Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: - Signature: Date: <br /> Print Name: Signature. Date: <br /> I'MEVSMPlanning Application Foms\Revisions of Approved Actons.00c Page 2 of 2 <br /> (Revised 05-11-09) <br />