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• - ; : P"IPLICATION - LOT L ` E ADJUSTMENT <br /> z` SAN JOAQUIN COUNTY COMMUMTi DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> M1-W- 1#7070 61-0- 010 0 <br /> E <br /> - <br /> .. <br /> p <br /> 1, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and <br /> F employees from any claim, action or proceeding against the Owner/Agent's project. <br /> l, further, certify under penalty of perjury that I am (check one): <br /> Legal property owner(owner includes partner, trustee, trustor, or corporate officer)of the property(s) <br /> involved in this application, or <br /> a <br /> ❑ Legal agent (attach proof of the owner's consent to the application of the property's involved in this <br /> application and have been authorized to file on their behalf., and that the foregoing application statements <br /> E are true and correct. <br /> Print Name: 510 C W SLC- Signature: Date: f Z z�z6 <br /> j Pritit Name: ddb 5s(NE KHhA 0 a i'J WU-icibsignature: Date: 6 <br /> Print Name: C'1ED�E NAAoTA,K15 Signature: Date: <br /> E <br /> Print Name: I110-r- i S Signature: Date: Lf <br /> r <br /> Print Name: Signature: Date:. <br /> i <br /> 1 <br /> 1 <br /> M <br /> I <br /> F1DEVSVCWIanning AWIcOon Forms% Page 5 of 7 <br /> Lot Line Adustment.doc.(Revised 64-04) <br />