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APPLICATION - REVISIONS OF APPROVED ACTIONS SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT FILE NUMBER: ,<iFORt' TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION Owner Information Applicant Information Name: W ctrlGl-VVI \1� X10-DV<. Name: Address: p 33 g W. 1-1 v- r— ed Address: --T—V-C �i I O A 0( c)4 Phone: Z -(DO -30 t l Z.00I -U 0 7-On+ Phone: PROJECT DESCRIPTION Proposal Revision to: Plk- 050044gg Map Condition(s)of Approval File No: 1. Description of the proposed Revisions: a ere Sc, �) v\n0 evev.i 5 2. State the fads showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. W e O-Ve 1 0-4 t vz Zj32 CkO O V1A&,r eA-t 2v east s 1-o e � idbk c. +-o u e- 0-vt ck wt AUTHORIZATION SIGNATURES ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. I, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and employees from any claim, action or proceeding against the County arising from the Owner/Agent's project. I, further, certify under penalty of perjury that I am (check ane): ® Legal property owner(owner includes partner, trustee, grantor, or corporate officer) of the property(s) involved in this application, or ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and have been authorized to file on their behalf., and that the foEagoing a tatements are true and correct. Print Name: UJ tWO-V-'1 Y'1 O SA-e Signatur Dat/a o?$4T Print Name: 3k0L\CL#-At Signature: Date: t0 2-4 12 Print Name: Signature: Date: Print Name: Signature: Date: Print Name: Signature: Date: F:IDEVSVCWIanning Application Fortns\Revisions of Approved Actions.doc Page 2 of 2 (Revised 05-11-09)