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APPLICATION - REVISIONS OF APPROVED ACTIONS Q' 2a SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT F. FILE NUMBER: PA 16 RIO-61 • c v7 �fFOM1� TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION Owner Information Applicant Information Name: r1 ; j2 O 1 Name: p O 1:—::/-� Address: !T /`lAu <« to. Address: 5 0 xA?1= E C vN & /4 5-366, Phone: Phone: (- 2= — C' PROJECT DESCRIPTION Proposal Revision to: �I ' IJ� MaP m ED �OLP Conditions) of Approval File No: File of the proposed Revisions: OR f 0/ a� � F UE � �E1GS 2. State the facts showing the changes in circumstances which make the subject condition(s) no longer appropriate �neecessary. PURI i? d w � o �Q�C6a5 nTRF 6 AG E P . F r 2T G TFI- pIDA(Zr- 6L 5s K cT HL o c v G - Pa c L O<1 o c P F l P RG L AUTHORIZATION SIGNATU S ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. 1, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and employees from any claim, action or proceeding against the County arising from the Owner/Agent's project. I, further, certify under penalty of perjury that I am (check one): Legal property owner(owner includes partner, trustee, grantor, or corporate officer)of the property(s) involved in this application, or application and El Legal agent(attach proof of the owner's consent to the application of the property's involved in this app have been authorized to file on their behalf., and that the foregoing alication statements are true and correct. Signature: l r`�'�`� Date: C; /y Print Name: Date: Print Name: Signature: Date: Print Name: Signature: Date: Print Name: Signature: Date: Print Name: Signature, F:\DEVSMI'lanning Application Forms\Revisions of Approved Acfions.doc Page 2 of 2 (Revised 05-11-09)