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APPLICATION - REVISIONS OF APPROVED ACTIONS <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> fC1n'tiYS'SFx?"N� F3pwt.FfrcdYStt '< <br /> EAPFtPG/kNTsINQtClZ7gFIL�IGTH�APPtIATION <br /> Ant hiformatiun <br /> Name• ry Name• -� <br /> Address: U ^O// Z2 J Address: <br /> 322,2 hone: <br /> 5 fii #1e..ttL.y< 4bekH�aHN YY1d t :5 <br /> y.F.," F,s.,.i "� <br /> JT t51EV. <br /> T,fJRIPTtON< : ,7�7 <br /> :: 6 ss sKsxYs 4 <br /> 3,,�Sr>n' `P.� R.�. <br /> Revision to: Me onditiords of A royal <br /> File No: i Lt <br /> L <br /> 1. Description ofv.posed Revisions: <br /> ci <br /> 2.CrJ .�TjS <br /> Ile <br /> T cfacts <br /> show <br /> in o t�1hYTNtt-�han2e�s In <br /> mEunistancins <br /> '-0which-m--�a� efhe-rsubject <br /> ub ect condition <br /> lI <br /> -2 no longer asJno ro n,$rGiate <br /> or n <br /> 4-0 <br /> cn2 r <br /> F,r"` AT:HOFtIZPiTiCON SIGNATURES <br /> ONLYTHE OWN99.OF.§CHE 04 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 <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 <br /> property(s) Involved In this application,or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's <br /> Involved In this application and have been authorized to file on their behalf.,and that the <br /> foregoing application statements are true nd correct <br /> I <br /> Print Name: J t'c''��""' " —"'"'"�Slonature: <br /> Print Name: ••... <br /> Print Name: Signature: Date: 'I <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> I <br /> -2- <br />