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APPLICATWIN - REVISIONS OF APPROVED ACTIONS <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: - <br /> • �4C%FORN`p•• _ <br /> _; TCf 6E GOIfAPkEED BY°7k[EAPPUCANT PRIOR 70 FILINCrTHE'APPLICATIOM <br /> § u 01�rriar Infotmattort ' :, RPpli aR�IrifO that[on <br /> Name: E._ Name' 7,411 At.. eek <br /> Address: l / s �, L� /)E Address: <br /> D i 62 Z <br /> Phone: 1C 4 . 339 , '7333 Phone: ALL 7 7 7 '7 <br /> $ kRECT14 'T ' qtr <br /> > ., . <br /> PYu0asal- <br /> Revision to: r✓5 9,c'2--CI Map ',k P _ I c7 —14 Condition(s)of Approval <br /> File No: <br /> 1. Description of the proposed Revisions: <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE 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 Owner/Agent's project. <br /> Ig,.fu her, certify under penalty of perjury that I am (check one): <br /> u(J 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 roof of the owner's consent to the application of the property's involved in this application and <br /> have been aut ize Ie on their behalf., and that the foregoing application statements are true and correct. <br /> g "/VC P C.C.I — Date: <br /> Print Name: �-t'� Signature: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F1DEVSVMRanning Application Fonns\Revisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 10-19-04) <br />