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t <br /> • z:� APPLICATION — LOT Llw"E ADJUSTMENT <br /> W. < SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> �� "' � :�F *°�AUTHORtZATION;SIGNATURES . <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED'AGENT MAY FILE AN APPLICATION. <br /> I, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and <br /> employees from any claim, action or proceeding against the Owner/Agent's project. <br /> I, 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 /> ❑ 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 /> are true and correct. <br /> Print Name: T��s�,A� &Z Z'g IL Signature: Data: <br /> Print Name: .iia /i'e' I ' Signature"' F Date:/ 0e9 <br /> Print Name: llew A.le& /fir,i4! � Signature: Date: �� <br /> Be <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: j <br /> I <br /> i <br /> I <br /> F;IDEVSVCParvdng App&mtbrt Fonnel Page 5 of 7 <br /> Lot Une Ad womnUW—(Revised"-04) <br /> of BahJ� <br /> 16-7/ <br />