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11/17/2009 12:38 FAX 209 474 FIAKEEM ELLIS & 11ARENG0 C 004/005 <br /> APPLICATION -- LOT LINE ADJUSTMENT <br /> '" :{ SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> �.: a :=. <br /> \no: <br /> FILE NUMBER' <br /> AUTHORIZATION SIGN"ATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> 1, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and <br /> employees from any claim, action or prodding against the Owner/Agent's project. <br /> I.further, certify under penalty of perjury that I am (check one): <br /> ❑ Legal property owner(owner includes partner, trustee, trustor, or corporate officer)of the property(s) <br /> involved in this application, or + <br /> ❑ regal agent(attach proof of the owner's consent to theIi ti of the propert)'s involved in this <br /> application and have been authorized to file on their ehalf_, nd that the foregoing application statements <br /> are true and correct. <br /> Point Name: �& A,rJO% hu-6o l& Signature_ Dale.Jr <br /> Point Name: O ! r <br /> K �� �__. Signad�r _ DBte: Y ,l Tr Jam" <br /> Paint Mame: -• - Signature: Late: <br /> (Print Name_ _ Signature. We. 1 <br /> i <br /> Print Name: Signature: Date. <br /> I <br /> i <br /> i <br /> a <br /> �i <br /> i <br /> t <br /> r <br /> i <br /> h:q)kVSV0P1Annng App5e3ewe Fwn-% Page 5 of 7 ' <br /> Lal Line Aa11J51meM.d0C.rRexisea 544)4� <br />