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<br /> - 001
<br /> APPLICATION
<br /> APPLICATIO
<br /> N - REVISIONS 'OF APPROVED ACTIONS
<br /> SAN'.lOAQUlN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT
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<br /> Address
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<br /> Revision to: Ma
<br /> 1
<br /> File No:
<br /> 1,
<br /> Descr-113on or oroposed Revisions: Ii7 v�'► ,��
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<br /> 2. State the facts showin the Chan es In circumstances which make sub ect�Q itlon s no Ion er date o ec`ssa
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<br /> .,: . AU�HaRh'AT�4�1fS.{:GN�TURES
<br /> eNL`Y;`CF #=.�WNEt.O THIS.PROPERTYi�R.AN"AUTHEQ:aGNT MAY FII. 1�N AP.PI.ICATION
<br /> I,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 penury that i am(check oneJ:
<br /> �pQ Legal property owner(owner includes partner,trustee, trustor, or corporate officer)of the
<br /> property(s) Involved In this application,or
<br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's
<br /> Involved In this application and have been authorized to file on their behalf.,and that the
<br /> foregoing application statements a true and correct.
<br /> 1
<br /> LA.J It,,
<br /> Signature:
<br /> Print Name:
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<br /> Print Name: �-••_� , ... __. •.------'—.-... .__ ;;:ae• �.�--_ ,I
<br /> Date*
<br /> Print Name: Signature:
<br /> . Signature: Date:
<br /> Print Name: Date:
<br /> Print Name:
<br /> Signature:
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<br /> -2- i
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