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T 4ly.. APPLICATION -- LOT 6NE ADJUSTMENT <br /> ` SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> p. AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> II .• <br /> I,the Owner/Agent agree,to defend,indemnify,and hold harmless the County and its agents, officers and employees from any claim, <br /> action or proceeding against the Qwner/Agent's project. <br /> .;i <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 this <br /> appllcatfon,or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and have been <br /> authorized to file on their behalf.,and that the foregoing application statements are true and correct. <br /> Print Name: JO Iy / <br /> ►'4 h �ty h i V%12- Signat <br /> Print Name: Sig lure: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date, <br /> I <br /> 1 <br /> I <br /> FADEMS1Plar"rig Apptketion FormslM m Subdkvlsion(Rev.12-09-01) Page 7 of 9 <br /> :i <br />