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APPLICATION -- LOT LWE ADJUSTMENT- <br /> SAN <br /> y � �• _ •{ <br /> JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> :fAU7HORIZATIONSIGNATURES <br /> ONLY THE OWNER OF THE.PROPERTY OR AN`AOTHQRIZED AGENT MAY FILE AN'APPLICATION. <br /> I, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and Its agents, officers and <br /> employees from any claim, action or proceeding against 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, 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 /> application and have been authorized to file on their behalf., and that the foregoing application statements <br /> are true and correct. <br /> Print Flame: Signature: ........... <br /> — Date: Z- <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> FADEMC ftnr"A.Wlc n Forma{ Page 5 of 7 <br /> La We A rlm(RrAW"-W) <br />