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(,ut <br /> APPLICATION - REVISIONS OF APPROVED ACTIONS <br /> � SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER:b44 <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Applicant Informatio <br /> Name: t5 Name: <br /> Address: na Address: <br /> S <br /> Phone: j= - Phone: <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: -0 3 Map Conditions)of Approval <br /> File No: <br /> 1. Description of the proposed Revisions: <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <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, 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 <br /> is application, or <br /> ❑ Legal agent (attach proof of the owner's consent to the applicationproperty's ' volved in this application and <br /> have been or'zed to file on their behalf., and that the fore do ments are true and correct. <br /> Print Name: SPIE✓ Ud Signature: Date: hp—/"If <br /> Print Name: Signature: Date: <br /> Print Name: Signature: _ Date: <br /> Print Name: Signature: - Date: <br /> Print Name: Sf nature: Date: <br /> F:\DEVSVG\Planning Application Fonns\Revisions of Approved ActionsAm Page 2 of 2 <br /> (Revised 10-1"4) <br />