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APPLICA,. jN — REVISIONS OF Ari'ROVED ACTIONS <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> ., FILE NUMBER: - R41v <br /> �tFOR� <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING.THE APPLICATION <br /> Owner Information Applicant Information <br /> Name: Q Name: 6t'i0(Wx69-,-) <br /> Address: %0 fi-6(0 } t Cp` &t- Address: (Q( <br /> oboa C.4 ql5 ( <br /> Phone: 2(jq s&1-2 <br /> X 52 <br /> ` PROJECT D8S?dk*TION <br /> Proposal <br /> Revision to: Map Condition(s)of Approval <br /> File No: <br /> 1. Description of the proposed Revisions: ((pt <br /> testi s 2 , <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <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 employees <br /> 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, grantor, or corporate officer)of the property(s) involved in <br /> this application, or <br /> Legal agent(attach proof of the owner's consent to the appl c tion of the property's involved in this application and <br /> have been authorized <br /> to�� file o their behalf., and that the f going application statements are true and correct. <br /> Print Name: � Lo ti Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:\DEVSMfolanning Application Foms\Revisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 10-10-04) <br />