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V'c APPLICATION - MINOR SUBDIVISION <br /> < SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPAR`%IEN- <br /> k .: FILE NO: NIS-__________ <br /> '9i..F oAy <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> I, the Owner'Agent agree. to defend, indemnify, and hold harmless the County and its agents, officers and employees from any claim, <br /> action or proceeding against the Owner/Agent's project. <br /> I further certify, under penalty of perjury, that I am (check one): <br /> ® Legal property owner(owner includes partner, trustee,grantor, or corporate officer)of the property(s)involved in this <br /> application, or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and have been <br /> authorized to fide on their behalf.,and 1'r�T <br /> that the foregoing application <br /> �statements are true and correct. <br /> Print Name: �Q6f "on1 L-Psn oiZ; o Signature: XAmeDate: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F OEVSVS%P!anning Application Forms\Miner Subdivision(Rev.6-03-04) Page 7 of 9 <br />