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� LICA-1 .^' LOT UNro,,t � <br /> i ; <br /> SAN;J.fffl'WN 00014V- 66MMOAft'r"b> pNi�N� DEPARTMENT <br /> f <br /> F" <br /> *6A*Ir AiAY .. gyp jand 1, the Oulu i/A nt>or$4, to--.ft ertd,_indemnifjr:and bold hdrmlaas thw County and its ager4s, t�ffioer <br /> et pi0yde$#t`otri any.Gtaitry,aptiritt.b�p�roCt3edin agafnet tii�L)uirnet/A�eht's prOct. <br /> 1,further,cetifji under p�lty tf 1Po.jury that i sm(check one): <br /> �f Legal properitiy wittier-f @r inciudes"pahn6r,trustee,ti irstgr,br corporate*Mmr)of the property(s) <br /> iiWolved 10 this opoficoitiatt,dr <br /> [J l a1 t gerit�(afkedh prdgf bf tila o�nlnat's:,t on9ent to tile,application t�f they pral7vrty`s itiv0ivad in this <br /> applldatiori atiidb beeft�auth6ftad'to Hle ori their behalf.,and thilt tics fo"oing-appacation statements <br /> am true.and correct. <br /> LNahio: <br /> .FMacd.sco.,J.- Ayala• Signature: CEc.Le.►t [late: �4 al <br /> 3ignet�te: _a r tate: <br /> Signatures Date:Signature: Date:,,_,..--• <br /> Signature: Date. <br /> FtDEYSVLW1annCsgAapltcatlon>zor�nal Page 6 of 7 <br /> Lot Lim Mjvttm"Ld i0.(rtrAvOIJ 04.04) <br />