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USE PERMIT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: UP- <br /> AUTHORIZATION SIGNATURES <br /> Only the Owner of the Property or an Authorized AgeM May File an Application <br /> /, the OwneNAgent, agree to defend,indemnify,and hold harmless the County and its agents, officers and employees from any claim, <br /> action or proceeding against the OwneNAgent's project. <br /> I further certify, under penalty of perjury, that I am(check one): <br /> l Legal property owner(owner includes partner, trustee,grantor,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: Signature: Date:.3-16-6q- <br /> Signature- <br /> Print <br /> IFi"�" <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: _ Signature: Date: <br /> Print Name: Signature: Date: <br /> UPAPPr-0RMREV 94S02flHD) 5 <br />