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L"T LINE ADJUSTMENT <br /> SAN JOAQUIN COUNTY COI: NITY DEVELOPMENT DEPARTMENT <br /> TH RIZATI IGNAT RE <br /> ONLy THE OWNEg OF THE PROPERTY ORAN AUTHORIZE0 AQEtJT1 T N <br /> I, the OwneNAgent agree, to defend, Indemnify, and hold harmless the County and Its agents, officers and employees from any claim, action <br /> proceeding against the Owner/Agent's project. <br /> 1, further, cortify 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 /> this application, or <br /> O Legal agent(aKach proof or the owner's consent to the appllcatlon of the property's Involved In this appllcatlon and <br /> have been authorized to Me on their behalf.,and that the foregoing application statements are true and correct. <br /> nr / <br /> Print Name: !�(;��u —7Cevj V1 Signature: �� Date:lG R- <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> „in.v.u.n/IbMM/PId1U1.1"I/14Y(LI NIALJAI.1./'OIW nry 2/1/)v _4_ <br />