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f <br /> A Ui <br /> APPLICATION - MINOR SUBDIVISION <br /> I ?<� SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> _ FILE NO: MS- <br /> �iF TF ORIZ#1E N 3IGNAT`UR <br /> e <br /> t�NLY,7FNw Q,., A�'I. �13 ,. o AN,/f 1lTHaIRIp I1GfJ'F Mii' iL1= N ►PL[Et!►f 1L)N <br /> i,the Owner/Agent agree,to defend,indemnify,and hold harmless the County and Its agents,officers and employees From any claim, <br /> action or proceeding against the County arising from the OwneriAgent's project. <br /> I further certify,under penalty of perjury,that I am(check one): <br /> ® Legal property owner(owner includes partner,trustee,grantor,or corporate officer)of the property(s)involved in this <br /> application,or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and have been <br /> authorized to fife on their behalf.,and that the foregoing application statements are true and correct. <br /> Print Name: mg •n ,t�S Signature: A4.41'e- /sr�.,s� 04ni�>/ Date: 51161 to j <br /> Print Name: o L {{ Signature: date; !;P&If <br /> Print{dame: �� � '� � �t"' Signature: � Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> r <br /> I <br /> r <br /> 1 <br /> r <br /> i <br /> I: <br /> F:IaEVSVS1Planning Application I'MMSkOnor Subdivision(Rev,p5-11-09) Page 7 of 9 <br />