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a� <br /> APPLICATION - REVISIONS OF M-PROVED ACTIONS <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: - <br /> f <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Applicant Information <br /> Name:Ok ri b iQ l�Yt _ p;-o Name:6)r w,�W G Ci - Cir t <br /> Address` J65q . S` �U Address (o 0' Ir <br /> r�i C•�1— r �,-�-, GGa- <br /> Phone: Oe 3 --�� Cc`so G1 Phone: =3_f ZI q C- O <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: �1 Map Condition(s)of Approval 4- <br /> k File No: <br /> l <br /> 1. Description of the proposed Revisions: <br /> Se �C-A-,? W 517'�e s <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 /> 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 County arising from the Owner/Agent's project. <br /> I, further, certify under penalty of perjury that I am (check one): <br /> t ❑ Legal property owner(owner includes partner, trustee, grantor, or corporate officer) of the property(s) involved in <br /> this 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 /> f have been authorized to file on their behalf., and that the foCegoing foregoingapplication statements are true and correct. <br /> Print Name: ('i Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> E Print Name: Signature: Date: <br /> 11 Print Name: Signature: Date: <br /> P%DEVSVCIPlanning Application FormslRevisions of Approved Actions.doc Page 2 of 2 <br /> (Revised(15-11-09) <br />