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°p4 APPLICATION - REVISIONS OF APPROVED ACTIONS <br /> � a <br /> y; ;t SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> ¢ FILE NUMBER k_ <br /> aeo? , '! <br /> �rF OiR� <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Applicant Information <br /> Name: hism o j C-k4rrdA Name: OfAe stp <br /> Address: v e. Address: 97Z //a <br /> raa CA, ?S37 i c <br /> Phone: 0-*U 4 i f- q57LCP Phone: 64)q3,.5-%- g 6 <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: Map Condition(s) of Approval <br /> File No: P - 040OLt7 <br /> 1. Description of the proposed Revisions: <br /> 1!P d <br /> 2. State the facts showing the changes in circumstances which make the ubject condition(s)no longer appropriate or necessary. <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENTMAYFILE 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 County arising from 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 owners consent to the application of the property's involved in this application and <br /> have been authorized to file on their'.behalf., and that the fore oin lication statements are true and correct. <br /> Print Name: Avid bt4* 1 Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> RX13EVSVC0anning Application Fons\Revisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 05-11-09) <br />