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°0.a.•." APPLICATON — REVISIONS OF ArPROVED ACTIONS <br /> Uf <br /> .-A SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> • �•. �� • FILE NUMBER: - - <br /> A�rFOR� <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Applicant Information <br /> Name: Q, C/,-S Name: r <br /> Address: 2 3013 S. Q J Address: <br /> CA CIS (, <br /> Phone. Phone: <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: Pa Corldition�,s;�ofAp/uova►; .� :�e <br /> File No: <br /> 1. Desc4ption of a,rw:•-m: cs nx. .. `�! <br /> t <br /> d <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> W 1 C/-u L' <br /> 9L C, o - <br /> r� { <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,fur r, 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 <br /> this application, or <br /> ❑ Legal agent (attach proof of the owner's consent to the application of the property's invo ved in this application and <br /> have been authorized to file on their behalf., and that the forego' .aIpplication state is are true.and correct. <br /> Print Name: SkA V-Q- S Signature: Date: - <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F\DEVSVC\Planning Application Forms\Revisions of Approved Actions.doc Page 2 of 4 <br /> (Revised 10-22-03) <br />