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g�tn. APPLICATION — LOT LINE ADJUSTMENT <br /> < SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> Nr FILE NUMBER: <br /> AUTHORIZATION 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 t foregoing application statements <br /> are true and correct. <br /> Print Name: TERRENCE J. CLARK Signature: �— <br /> Print Name: PAULETTE T. CLARK Signatur . Date:\- <br /> Print Name: RAFAEL VIRAMONTES Signature: Date: <br /> Print Name: SUSANNA BARELA Signatur Dat1 S 401 <br /> Print Name: Signature: Date: <br /> FADEvsvc'PlanningApplication Fonns\ Page 5 of 7 <br /> Lot Line Adjustment.doc.(Revised 64-04) <br />