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UPISAIIP <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION, <br /> 1,the Owner/Agent agree,to defend,indemnify,and hold harmless the County and its agents,officers and employees from any <br /> claim,action or proceeding against the Owner/Agent's project. <br /> ],further, certify under penalty of perjury that 1 am(check one): <br /> ❑ Legal property owner(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) <br /> and that the foregoing application statements are true and correct. <br /> Print Name: Signatures <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Mountain HouseWH;Application FormsMH-UP-SA-IP form-MASTER.doc <br />