SU0007631 - Laserfiche WebLink

Home Browse Search

GPQurry44 APPLICATION - REVISIONS OF APPROVED ACTIONS : ' a SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT on � • . . .� FILE NUMBER : - 9 4 �jFoR� TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION Owner Information Applicant Information Name : 1 Name : �' r✓l. VL "x Vii. I Iowa" Address : 1 (d I ' ' Address : -�'�`f a 1✓ " V Phone : �(� ci ® `�i Phone : C' M '�" � Z � Z� aw PROJECT DESCRIPTION Proposal Revision to : Map Condition (s) of Approval File No : 1 . Description of the proposedggRevi ions : ;c. l(� 1 ) d%L4, . q V Z 2 . State the facts showing the changes in circumstances which make the subject condition (s) no longer appropriate or necessary . Tx//14/ star k) :IT/I. ss� AUTHORIZATION SIGNATURES ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION . I , the Owner/Agent agree , to defend , indemnify , and hold harmless the County and its agents , officers and employees from any claim , action or proceeding against the County arising from the Owner/Agent' s project . I , further, certify under penalty of perjury that I am ( check one ) : Legal property owner ( owner includes partner, trustee , grantor, or corporate officer) of the property ( s ) involved in this application , or ❑ Legal agent ( attach proof of the owner' s consent to the application of the property' s involved in this application and have been authorized to file on their behalf. , and :-that the foregpingapplication statements are true and correct . JZ�o� Print Name : f f' ,1/ t l�- t/YL Signature : {� � � -- �'" Date : d �?' Print Name : Signature : Date : Print Name : Signature : Date : Print Name : Signature : Date : Print Name : Signature : Date : PTEVSMPlanning Application Forms\Revisions of Approved Actions . doc Page 2 of 2 (Revised 05 - 1 1 -09)