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PAGE 64 <br /> �= <br /> -- APPLICATION -- LOT L�tQE AUJU5TMENT <br /> ,4 Sm.rowgtprl>t county commurf r oEvELame r DEPARTMENT <br /> ;� • FILE MUNIM: <br /> { <br /> OIYt,.Y TME��.M if5pr <br /> .ATS N. <br /> 1, tote OWMWAgent BPP% to defend, Wkwaffly► SW hW hamdew the Omi" And Rs W-tis. officers and <br /> ernpk""from any claim.acdon ar pr+QO"WQ 890st the Owner/Agerrre projed. <br /> I,further,certify under perjolty Of perjury that I am(check onek <br /> fia"Legal Property owner(owner Includes partner,tntstee.trustor, or corpnrete o'lhcer)of the praperty(s} <br /> Involved in this app tion,a . <br /> ❑ Leo apent(aftc+•Irwr of the awtws=sort to the appltcetlon of the mmerty s InmNed In this <br /> applimbon and have been audwAted to Me on tttetr beha f.,and that the f tgnlrtg application staWtenta <br /> are true and carred. <br /> PrIM Name! 7V StAT1etLw Upt6' <br /> Pr%t Now dmwgez— at DOW <br /> Date: <br /> - Pr1nt NtNTIe• , <br /> DoW <br /> Print Nttrne: m.. Date. <br /> L ,e'erWM-ft F Psge 5 of 7 <br /> A <br />