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JA <br /> f J�gaa�r 'tTk4-.''Y'!' i _`.,• 4 ? •.x�-S �R, <br /> rf - - gPSAtJ JAOAQ <br /> L4T Lly- ADJ,USTMENT <br /> UIN COUNTYCOMMUNiTY.DEVEOPMN' <br /> DEPARTMENT <br /> FILE NUMBER <br /> AUTH0RIZAT[ON S'IGNATVRE$��� <br /> y:ONt.Y THEQWNER OFA p "� <br /> r4GE MAY Flt .gN APPLICATION <br /> 1, the towner/Agent agree, to defend, indemnify, and hold hatmless:the:County.and Its agents, officers and <br /> empfoyeas from any claim,action or prooeeding agalrist the Owner/Agent's project.. <br /> 1,further, certify under penalty of perjury that I am (check one): <br /> (Legal property owner.(awner::lncludes partner,trustee, trustor, or corporateofficer)of the property{s) <br /> volved in this `or <br /> i ❑ Legal agent(attach proof of the owners consent to the application of-the property's Involved In this <br /> application and have been auttiorizetl to fife on their behalf.`arid that the foregoing application statements <br /> are true and comer.: . <br /> PMt Name: . C r signature: Date: V <br /> Print Name:. Signature: Date: <br /> F%nt Name: Signature: -- — <br /> Date:, <br /> Print Name.,. Signature: <br /> Date: ! <br /> Print Name: Signature: <br /> Date: j <br /> Page 5 of 7 <br /> �.or�n. +�+e.doc.{rterraoa efo�) <br />