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ii <br /> APPLICATION -- LOT LINE ADJUSTMENT <br /> STMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> f 4�! FILE NUMBER: <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE A <br /> 1, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its a APPLICATION, <br /> employees from any claim, action or proceeding against the Owner/Agent's project. gents, officers and <br /> i� <br /> 1, further, certify under penaity of perjury that I am (check one); <br /> Legal property owner(owner includes partner, trustee, trustor, or corporate officer) of the property(s) <br /> involved in this application, or <br /> ❑ Legal agent (attach proof of the owner's consent to the application of the property's involved in this <br /> application and havebeen authorized to fife on their behalf., and that the foregoing application statements <br /> are true and correct. ii <br /> Print Name: <br /> Signature: / eqe <br /> Print Name: � _ <br /> Signature: Date: <br /> Print Name: Date: <br /> Signature: �-- <br /> Print Name: Date: <br /> !� Signature: <br /> Print Name: Date: <br /> Signature: '— <br /> ;1 Date: <br /> I r <br /> I <br /> i <br /> i <br /> I <br /> M1 <br /> li <br /> I� <br /> RMEVSMPlanning Application Forms{ <br /> Lot tine Adjustment.doc.(Revised 6-4-04) Page 5 of 7 i <br /> i <br />