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APPLICATION - SITE APPROVAL <br /> * a !s �,,,,yy sa`yak iso r��y"x3*"� '' <br /> } ry,.:l SrJik VA "1g, <br /> Q <br /> '77,7; <br /> }, ? s. K 3�k ,a>:, r¢es ;�",tt x. „ <br /> + _ I7Fa ^ <br /> x »3' x r r+i k '. ri� ➢ "fid -'x rA �' 4fit k <br /> � � x .t s� ',n> „, tEP.� ➢ ern K 5 s�5� s �Y>�- e4.'s p.ik$ ��^,� � i r € ;".�" '-�s.,. <br /> 0115 MVM <br /> A ,. .. ,.a <br /> and <br /> 1, the Owner/Agent agree, to defend, indemnify, and hold <br /> ar Owner/e Coos project agents, officers and <br /> a <br /> employees from any claim, action or proceeding against <br /> 1, further, certify under penalty of perjury that l 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 /> a plication and have been authorized to file on their behalf., and that the foregoing application statements <br /> are true and correct. <br /> Print Name: �/2/Y!� �MwC Signature: — <br /> Date:b —�y <br /> Print Name: <br /> Signature: Date: <br /> Print Name: <br /> Signature: Date: <br /> Print Name: <br /> Signature: Date: <br /> Print Name: <br /> Signature: Date: <br />