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°Acc APPLICATION — LOT LINE ADJUSTMENT <br /> N: :< SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> •.� �,FOR�`P. FILE NUMBER: <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 <br /> employees from any claim, action or proceeding against the County arising from 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, 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 /> Manuel J.Costa,Jr.and Patricia K.Costa as co-trustees of the Manuel J.Costa,Jr.and Patricia K. Costa Revocable Trust, <br /> under Declaration of Trust dated January 30, 2001 <br /> / ? f� <br /> Print Name: Manuel J. Costa,Jr. Signature: C��� �`` �- " Date: J 3— 1 i <br /> Co-Trustee <br /> Print Name: Patricia K.Costa Signature: LL �� ��1 Date: '~I <br /> Co-Trustee <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FADEVSVOPlanning Application Forms\ Page 3 of 3 Job No 2013-257 LLA.doc <br /> Lot Line Adjustment dor.(Revised 05-11-09) <br />