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n <br /> APPLICATION - LOT LINE ADJUSTMENT <br /> s <br /> .•�,,f�, SRN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> AUTHQR!&ATlQN,r <br /> � ;�.1.4.�t�v�S�fi�I.1 31i,i, f�3 � <br /> ONLY THE OWNER O THE PROPERTY dR AN�►f1THOIiIZ b�A�3�NY..MAIf` ILE AN`APPItICAT[ON <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 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,trustor, or corporate officer)of the property(s) <br /> involved in this application, or <br /> owners consent to the application of theproperty's involved in this <br /> ❑ Legal agent (attach proof of the ow s pp <br /> application and have been authorized to file on their behalf., and that the foregoing application statements <br /> are true and correct. <br /> i <br /> Print Name:l O U G G e. Signature' &� � I$ l <br /> Print Name: Signature: ---— Date: <br /> r <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date= <br /> s <br /> i <br /> F:)DEVSVC\Planning Application Forms\ page 5 of 7 <br /> Lot Line Adjustment.doc.(Revised 05-11I-M) <br />