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c° APPLICATION — LOT"LINE <br /> ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> . ���% �;R '4• FILE NUMBER: <br /> T <br /> 9 _ <br /> -t8 <br /> .4101 ? <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 /> 1, 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 Name: Dan Van Groningen Signature" <br /> Date: <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 /> I <br /> ,I <br /> I <br /> i <br /> F:\DEVSVC�Pianning Application Fomes\ Page 3 of 3 Job No 2009-163 LLA.doc <br /> Lot Line Adjustment.doc.(Revised 6-4-04) <br />