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LOC INE ADJUSFMENT <br /> SA A !N COUNTY C MMUNITY DEV LOPMENT DEPARTMENT <br /> 1,the Owner/Agent agree,to defend,Indemnify,and hold harmless the County and Its agents,officers and employees from any claim,action or <br /> proceeding against the Owner/Agent's project. <br /> 1,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 <br /> this 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 <br /> have been authorized to file on their behalf.,and that the foregoing application stat nts are true and correct. <br /> Print Name: 9 <br /> Si nature: Date:%,Z- %5~'OX <br /> O n G� C CU <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name., �.d�. ®� ``C = Signature: Date: <br /> Print Name: Signature: Date. <br /> 1 <br />