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APPLICATION -- LOT LINE AD <br /> � JUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> Cli±g ' <br /> [J� C R�ZAT OI SIGN IT 3F'E <br /> Rc <br /> u3 <br /> pVyNER4�OF•ITHEI�R�PR`l'Y„O.R,AN ►U,TFCCRI�ED"AGEN7xMAY FILE#ANr'il?�LICIATIQN'`` <br /> I, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and <br /> employees from any claim, action or proceeding against the Owner/Agent's project. <br /> i <br /> I, fu her, certify under penalty of perjury that I am (check one): r <br /> I` <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 have been authorized to file on their behalf., and that the foregoing application statements f <br /> are true and correct. <br /> •�Name�' C1IL/�� ��. ,� �, //,E Signature <br /> Print Name: _«ley f7l�rAL,1 Signature: Date: - /0 <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> RTEVs MIanning Appllaatton Forms.1 Page 5 of 7 <br /> Lot Line Adjustmantdot.(Revised 6-4.04) <br /> is <br />