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bw 7 f <br /> -)T LINE ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY I7EVL <br /> LOPMENT pEPARTMENT <br /> s � <br /> . pli7'NORIXATIONBk7ldA�7111ttr'3 <br /> ONLYTN�CWNRCI,1�!$:pRbPERTt'OR.4f�.AilTNC17lZAi4�SN7MAYPli�AN /iAAL1CA!]bN <br /> 1,the Owner/Agent agree,to defend,Indemnify,and hold harmless the County and Its agents,officers and employees from any claim,action or <br /> proceeding against the Owner/Agent's project <br /> 1,further, certify under penalty of perjury that 1 am(check one): i <br /> I <br /> Legal property owner(owner Includes partner,trustee,trustor,or corporate df8co of the property(s)Involved In this <br /> application,or <br /> Legal agent(attach proof of the owner's consent to the application of the property's Involved In this application and have <br /> been authorized to file on their behatt,and that the foregoing application statements are true and correct <br /> f • 1.-/102- <br /> me: SI-42rP t? *�rtri c4 ,_ Signature: Date: <br /> Print Name: 0� t �l�tSignature: Date: <br /> Si <br /> Print Name: nature: Date:g <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> I <br /> f <br /> 10-.W RMPA-LAN FQ&W7 1.1999 <br /> -4- <br />