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° ti 73 T LINE ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> •AurHomzAmN SIGNATURES <br /> ONLYTH0OWNEAPF TN,E PROPERTY dR AN AUTHORIZED AGENT MAYFILE AN.APPUCATION <br /> 1,the Owner/Agent agree,to defend,lndemnify,and hold harmless the County and its agents,officers and employees from any claim,action or <br /> I <br /> proceeding against the Owner/Agent's project <br /> 1,further, certify under penalty of perjury that 1 am(check ane): <br /> Legal property owner(owner Includes partner,trustee,trustor,or corporate officer)of the property(s)Involved In this <br /> application,or <br /> O Legal agent(attach proof of the owner's consent to the application of the property's Involved In this application and have <br /> been authorized to Tile on their behalf.,and that the foregoing application statements are true and co ect. <br /> c] , <br /> Print Name: �� G p Signature: �d Date: 1'� b <br /> s <br /> Print Name: Signature: Date: { <br /> Prinf Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> I <br /> Print Name: Signature: Date: I <br /> j <br /> I <br /> 4 v <br />