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APPLICATION - REVISIONS OF APPROVED ACTIONS <br /> y: A < SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Applicant Information <br /> Name: 1�1g}-1 N,I_1 Name:1C!$_.N <br /> Address: Address: Pa $p <br /> G G %V'q 1 C CA t <br /> Phone: &� (a Phone: <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to k :(5 ap Condition(s) of Approval <br /> File No: <br /> 1. Description of the proposed Revisions: <br /> h,fl�� c)vi 'C <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 foregoing application statements are true and correct. <br /> Print Name: Signature: 1, Date: II a7 Q <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:\DEVSVC\Planning Application Forms\Revisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 05-11-09) <br />