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I <br /> {" APPLICATION - REVERSION OF ACREAGE <br /> y, SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> • ct,;- .; FILE NO: RA- <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 <br /> employees from any claim, action or proceeding against the Owner/Agent's project. <br /> a I, further, certify under penalty of perjury that I am (check one): <br /> i <br /> IN Legal property owner (owner includes partner, trustee, trustor,or corporate officer) of the property(s) <br /> involved in this application, or <br /> 0 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 /> Print Name: ���✓s4LID G Lw—A2— Signature: � Date: <br /> Prins Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br />{ <br /> i <br /> l <br /> r <br /> F <br /> F:IDEVSVCIPIanning Application Forms\ Page 4 of 5 <br /> Reversion of Acreage.doc(Revised 6-3-04) <br />