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S, � eAPPLICATION — LOT �iNE ADJUSTMENT <br /> `PL w SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> 1, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and <br /> employees from any claim, action or 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, trustor, 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: Johnnie L. Costa Trustee Signature: * a Date: lt� ( G <br /> Print Name: Josephine L. Costa, Trustee Signature: c L c Date: ID <br /> Print Name: Signature: Dale: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: pate: <br /> h <br /> I <br /> k <br /> F:IDCVSVC\PIanning Application FormM Page 3 of 3 Job No 2004-144 LLA <br /> Lot Line Adiustment.doc.(Revised 6-4-04) <br />