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Pa�,N APPLICATION — REVISIONS OF APPROVED ACTIONS <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: - PA " 9000 "g4 <br /> 4Giko RN�h <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Applicant Information <br /> Name: "11*A-11I7— 0VA*(11—(— Name: <br /> Address: & 00K *-3 Address: 18, 2- N- A+IGt M $ 0-0kc <br /> VI CIV tL C A- 4 Q66 v p <br /> Phone: ZV — t"13 3 Phone: ?7;;F (j <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: PA-010000 Map Condition(s)of Approval <br /> File No: <br /> 1. Description of the proposed Revisions: <br /> ,/ (/✓OL L �6(L N//�'Cli <br /> v, A- - I t IQ 00 <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s) no longer appropriate or necessary. <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> I, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and employees <br /> 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 (check one): <br /> Legal property owner (owner includes partner, trustee, grantor, or corporate officer) of the property(s) involved in <br /> this application, or <br /> ❑ Legal agent (attach proof of the owner's consent to the application of the property's involved in this application and <br /> have been authorized to file on their behalf., and that the foregoing application statements are true and correct. (� <br /> Print Name: YI(2,&t 4-h a ,J e � Signature: Date:j(J <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:\DEVSVC\Planning Application Forms\Revisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 05-11-09) <br />