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- SAN.�JOAQUIN
<br />_.--- c o (� N -r v --
<br />COMMUNITY DEVELOPMENT DEPARTMENT
<br />ADMINISTRATIVE/CONDITIONALp MUSE PERMIT
<br />FILE NUMBERI �T--300 �/�G'
<br />LEVIN�I`ACT
<br />Effective January 1, 2023, California Political Reform Act of 1974, Government Code § 84308, known
<br />I have read and untl erstand
<br />that this application �s
<br />as the Levine Aci, prohibits any San Joaquin County Boartl of Supervisor member from participating in
<br />subject to these provisions:
<br />any agenda item involving a discretionary land use permit or other entlilemants If the Board member
<br />has received any political contributions from the ownaq applicant, or agent for the owner or applicant
<br />�/ S
<br />6-I�itial
<br />totaling more Shan $250 in the 12 months before the decision (but not before January 1, 2023) and for
<br />the 12 months following the tlacision. Tha Act also prohibits an owner, applicant, or agent for the owner
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<br />or applicant from making a contribution of mora than $250 to a member of the Board of Supervisors
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<br />while the item is pending and for the 12 months following the date a final tlacision is rendered.
<br />Date
<br />' AUTHORIZATION SIG NATU RES '
<br />ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAV FILE AN APPLICATION
<br />I, the Owner/ApplicanVAgant agrees to Intlemnify, defend (with c sel reasonably approvetl by County), and hold harmless the County
<br />and itsoTficers, officials, employees, agents, boartl santl commissions (bollactivaly"County")'as follows:
<br />1. INDEMNITY:
<br />A. From and against any end ell claims, tlamanda, actions, proceetlings, lawsuits, losses, damages, judgments antl/or
<br />liabilities arising out of, relafetl to, or in connection with the application antl applied for project or [o attack, set aside, void, o nul, in
<br />whole or In part, an approval of the applied 4or project by the County, the adoption of environmental ra w documents related to the
<br />applied for project, and any related development approvals or project conditions fortha applied for project (hereinafter"Claim"):
<br />B. For any antl all costs and expenses incurred by'the County on account of shy Claim, a cept where such intlemnification is
<br />prohibitetl by law, Including but riot limited to tlameges, costs, expenses, attorney's fees, or expert witness costs that may ba asserted
<br />by any person or entity, private attorney generel fees claimetl by dr awartlatl to -any party against tM1a County, and the County's costs
<br />incurretl In preparing an administrative recoriJ which a not paitl by the petitioner.
<br />C. Except as to the County's sola nagli9ance or willful miscontluct.
<br />2. DEFENSE:
<br />A. Tha County may participate or direct the defense of any Claim. The County's actions in defense of any claim shall not
<br />relieve me of any obligation to Indemnify, defend, and hold harmless the County.
<br />B. In the evens of a disag raement between County and ma regarding defense of any Claim. the County shall have fha
<br />authority to control the litigation end make litigation decisions, Inclutling, buF not limi[atl to, the manner In which the defense is
<br />onductaa.
<br />C. If the County reasonably determines that having common counsel presents such counsel with a conflict of interest, or if I
<br />fail [o promptly assume [ha defense of any Claim or to promptly employ counsel reasonably satisfactory fo thaCounty, then County may
<br />utilize the Office of the County Counsel or employ separate outside counsel to represent or defend the County, antl I shall pay the
<br />reasonable attorneys' fees antl costs of such counsel.
<br />I, furthan certify untler penalty of pa jury that I am (check one):
<br />� Legal property owner (owner Includes partner, trustee, trustor, or corporate officer) of the property(s) involved in this application, or
<br />„0� Legal agent (attach proof of the owner's consent to the application oT the properties involved in this application) and have bean
<br />authoriz'e/d�to/fila on their behalf, and Shat the foregoing application statements era true and correct.
<br />SW%��n �� Data: ��' � �%z3
<br />Print Nama: RGtr�N Signature:
<br />Print Nama: Signature: Data:
<br />Print Name: Signature: Data:
<br />Print Nama: Signature: Data:
<br />Print Name: Signature: Data:
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