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t E I S i -!- J d- <br /> 1 ,h <br /> L 0 T LINE ADJUSTMENT <br /> .I <br /> SA A C TY C MM NITY DRV L PM NT DEPARTMENT <br /> 7A f <br /> !, the Owner/Agent agree, to defend,Indemnify,and hold harmless the County and Its agents,officer <br /> Proceeding against the Owner/Agents project <br /> Officers and employees from any clam,action or <br /> 1, further,j certify underpenalty of-; undp tY perjury that I am(check one): <br /> E don,orner(ownerincludes partner, trustee,grantor, or corporate officer)of the property(S)tnvotved in <br /> X't�Log.alp1roperty <br /> ispication,or <br /> i <br /> Legal agent(attach proof of the owner's consent to the property's Involved in this application and <br /> applicatio <br /> have been authorized to file on their behalf.,and that the fore oin a n of thehe <br /> g g PP statements are true and correct. <br /> Print Name: <br /> Signature: <br /> Print Name; �� �+,� Date:/�I/)/;3 <br /> LL Signature: <br /> k� Print Name: Date: <br /> Signature: <br /> Print Name: Date: <br /> l Signature: <br /> k; Print Name: Date: <br /> Signature: <br /> Date: <br /> 1 <br /> II 4 <br /> I <br /> 1 , <br /> i <br /> [I <br /> J <br /> �r •r-aabe f �.__tS+[lbw+ln....`'s-a�w'�� -X..�w'.' _.+2+-�tiR---"` T—i".' �4 �.s� �4�.:a- '_�'fw, Y[Tr +s��.a.�-.s r -i�'��'�. , <br /> I <br /> a <br /> I' <br /> kI [ <br /> I <br /> E <br /> F I <br /> [oxvsGRf7MA]t/PGWAP73/fATL2aLMJAePIO..RN.... <br /> -q- <br /> >I <br />