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°AaUI ty. A LICATIQN — LOT Li ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY'u=VELOPMENT DEPARTMENT <br /> •. "_.-�c FILE NUMBER: <br /> y L'AUTHORIZATION :SIGNATURES' 3 <br /> ONLY THE;'OWNER OF THE,PROPRTY;OR A,N_AUTHORIZED.AGENT':MAY,FILE ANAPPLICATION , <br /> 1, the 6wner7Agent 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 /> li <br /> 1, further, certify under penalty of perjury that l am (check one): <br /> Legal property owner (owner includes partner, trustee, trustor, or corporate fficer) of the property(s} <br /> involved in this application, or <br /> II � <br /> ❑ Legal agent (attach proof of the owner's consent to the application of the prparty's involved in this <br /> application and have been authorized to file on their behalf., and that the forgoing application statements <br /> are!true and correct, f` <br /> li / <br /> Print Name: Signature: - w J � ° Date, GT�' <br /> Print Narrie: Signature: / Date: <br /> Print Name: Signature: / Date: <br /> i <br /> Print Name: Signature: / pate: . <br /> Print Nam 11 Signature: Date: <br /> ii <br /> �I <br /> Ei <br /> it <br /> I' <br /> c - <br /> I` <br /> J <br /> i <br /> I <br /> li <br /> !E <br /> li <br /> ':1DEVSVCIPlanning Application Form sl Page 5 of 7 <br /> of Line Adjustment.doc.(Revised 6-3-03) <br /> it <br /> f! <br /> l <br /> H <br />