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1-03./01/2006 14:40 FAX 209 932 o8an R&B CONSTRUCTION Q003 <br /> APPLICATION - REVISIONS OF APPROVED ACTIONS <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> ' Fo <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information - AppllcintInformation <br /> Name: Name: <br /> Address: 14 Lo k 9r Address: <br /> 0 <br /> Phone: (o Phone: <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: Map Condition(s)of Approval <br /> File No: <br /> 1. Description of the proposed Revisions: eg el <br /> 2. State the facts showing the c 19,88 In circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> hall-p <br /> AUTHORIZATION SIGNATURES <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 employees <br /> from any claim,action or proceeding against the Owner/Agent's project. <br /> 1,further,certify under penally 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 application of the property's involved in this application and <br /> have been authorized to file on their behalf.,and that the for oi.ng application statements are true and correct. <br /> Print Name: Kon6fd j( 134ur t�J�_ Signature: Date:31 <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature,— Date: <br /> F13EVSVC%PIanning Appli ion Forms\Revisions of Approved Aplipns.dm Page of <br /> (Revised 10-1004) <br />