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br <br /> APPLICATION - REVISIONS OF APPROVED ACTIONS <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> •:�dc � `�:a FILE NUMBER: _ 1- 060011 � <br /> Fou i <br /> { TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Applicant Information <br /> Name: (^jr ty G� Ci1J i1e Name: <br /> iAddress: 'R 0 Address: I <br /> Phone: �(p 2—q Phone: (0 0 i <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: Map Condition(s)of Approval <br /> File No: <br /> 1. Description of the proposed Revisions: <br /> I <br /> f <br /> i <br />' I <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary,. <br /> 0 <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 <br /> from any claim, action or proceeding against the Owner/Agent's project. <br /> i,further, certify under penalty of perjury that 1 am(check one): <br /> 9 Legal property owner(owner includes partner, trustee, grantor,or corporate officer)of the property(s)involved in <br /> this application, or <br /> Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and <br /> have been a2Mnued to file on their behatf.,and that the foreoDing Aoication statements are true and correct. <br /> Print Name: ,0^ pSignature: Date— <br /> Print <br /> Name: <br /> Signature. l Date:All, <br /> l <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature Date: <br /> ROEVSVOPlanning Application Forms ftvisions or Approved Acbons.doc Page 2 of 2 <br /> (Revised 10-19-O4) <br />