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APP LICATION SITE APPROVAL <br /> 9AN JQAQUlt COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: A- <br /> + Other <br /> Describe any Hems of hisl6rica7 or archaeolb'1001 in1dfW'gh-site' e, ."eterte5 or swciures <br /> NONE <br /> Describe any on-site or off-site soilrces of noise or vibration e. . eWay noise bea ui ment eta :. <br /> 721 Case, <br /> 00 f <br /> Describe an on-site or off=site sources of light of cafe (d.- .oarkind lot li htin 'or reflective materials used): <br /> ee <br /> Describe any on-site or off-site source of odor e. .a riurtturaf wastes: <br /> G(Ppo clippings <br /> Describe aU dis lacemeht of peclole that will be caused by the Prolelet Le.g.numbers of people,housing units): <br /> NONE <br /> I <br /> AUTHORIZATION SIGNATURES <br /> I <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGIENT MAY FILE AN APPLICATION. <br /> 1, 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 County arising from the Owner/Agent's project. <br /> I,further, certify under.penalty of perjury that I am (chelk one): <br /> [l Legal property owner(owner includes partner,trtFstf1e,trustor, or corporate officer)of the property(s) <br /> l <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: Hmberto_Valdez Signature: Date:,,�tJ <br /> Print Name: Lvl,nda Dpiguir ir-e Signature^ Dater <br /> Print Name:. .Signature: � _ Date:- <br /> Print Name: Signature: _ !i Date: <br /> Print NamO: Signature. Date: i <br /> F.VEvsvclP mningAppucad=FormstsnanWovai.(Re*eaoz.as-io) Pag 5 of 9 t <br /> e <br />