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* ' APPLICATION - LOT,,- INE ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> S <br /> AUTHORIZATION SIGNATURES <br /> 't <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> i <br /> 1, 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 Mame: ROBERT BROCCHINI Signature: Date: <br /> Print Name: i� Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> 1 <br /> } <br /> t <br /> r <br /> F:TEVSVC1P1anning Application Forms\ E; Page 3 of 3 Job No 2008-123 LlA.doc <br /> Lot Ltne Adjustment-doc.(Revised 84-04) <br /> F <br />