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_OT LINE ADJUSTMENT <br /> SAN JOA QUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> _ �[[r77iORlTJ177'OA151GN47YiRL8" <br /> ,. ... ;�. =,... CJNf„YTS'I�.Q�YA1Bi:01�7'��.�*la�F�P�7YQRNtif`I4LITJ�i�Rf�t3Ah�Fli'A�,4Y:�i,�7lA►:'4PPL'IG47?bN,,.,,' -' <br /> 1,the Owne#Agent agree,to defend,Indemnify,and hold harmless the County and Its agents,officers and employees from any claim,action or <br /> proceeding against the Owner/Agent's prgfwt <br /> 1,further, certify under penalty of pedury that I am(check one): <br /> Q Legal property owner(owner includes partner,trustee,trustor,or corporate officer)of the properiy(s)Involved In this <br /> application,or <br /> O Legal agent(attach proof of the owners consent to the application of the property's Involved in this application and have <br /> Leen authorized to file on their behalf.,and that the foregoing application statements are true and correct. <br /> Print Name: F Signature: 1 Data: ! p <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> I <br /> i <br /> i <br /> I <br /> j <br /> i <br /> I <br /> 10:04 AMPA_1.A98 FaMw71.10W <br /> —4— <br />