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- SAN.�JOAQUIN COMMUNITY DEVELOPMENT DEPARTMENT
<br /> ' ----co(� nl-ry-- ADMINISTRATIVE/CONDITIONALp MUSE PERMIT
<br /> .��nc.. ,.�, nr.c. FILE NUMBERI �T- - 300�/�G'
<br /> LEVIN�I`ACT
<br /> Effective January 1, 2023, California Political Reform Act of 1974, Government Code§84308, known I have read and untl erstand
<br /> as the Levine Aci, prohibits any San Joaquin County Boartl of Supervisor member from participating in that this application �s
<br /> any agenda item involving a discretionary land use permit or other entlilemants If the Board member subject to these provisions:
<br /> has received any political contributions from the ownaq applicant, or agent for the owner or applicant �/S
<br /> totaling more Shan$250 in the 12 months before the decision(but not before January 1,2023)and for 6-I�itial
<br /> the 12 months following the tlacision. Tha Act also prohibits an owner, applicant, or agent for the owner /�J p Z3
<br /> or applicant from making a contribution of mora than$250 to a member of the Board of Supervisors Z r Qp - Z(7
<br /> while the item is pending and for the 12 months following the date a final tlacision is rendered. Date
<br /> ' AUTHORIZATION SIG NATU RES '
<br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAV FILE AN APPLICATION
<br /> I,the Owner/ApplicanVAgant agrees to Intlemnify, defend (with c sel reasonably approvetl by County), and hold harmless the County
<br /> and itsoTficers,officials, employees, agents, boartl santl commissions(bollactivaly"County")'as follows:
<br /> 1. INDEMNITY:
<br /> A. From and against any end ell claims, tlamanda, actions, proceetlings, lawsuits, losses, damages, judgments antl/or
<br /> liabilities arising out of, relafetl to, or in connection with the application antl applied for project or[o attack, set aside, void, o nul, in
<br /> whole or In part, an approval of the applied 4or project by the County,the adoption of environmental ra w documents related to the
<br /> applied for project, and any related development approvals or project conditions fortha applied for project(hereinafter"Claim"):
<br /> B. For any antl all costs and expenses incurred by'the County on account of shy Claim, a cept where such intlemnification is
<br /> prohibitetl by law, Including but riot limited to tlameges,costs, expenses,attorney's fees,or expert witness costs that may ba asserted
<br /> by any person or entity, private attorney generel fees claimetl by dr awartlatl to-any party against tM1a County, and the County's costs
<br /> incurretl In preparing an administrative recoriJ which a not paitl by the petitioner.
<br /> C. Except as to the County's sola nagli9ance or willful miscontluct.
<br /> 2. DEFENSE:
<br /> A.Tha County may participate or direct the defense of any Claim. The County's actions in defense of any claim shall not
<br /> relieve me of any obligation to Indemnify,defend, and hold harmless the County.
<br /> B.In the evens of a disag raement between County and ma regarding defense of any Claim.the County shall have fha
<br /> authority to control the litigation end make litigation decisions, Inclutling, buF not limi[atl to,the manner In which the defense is
<br /> onductaa.
<br /> C. If the County reasonably determines that having common counsel presents such counsel with a conflict of interest,or if I
<br /> fail[o promptly assume[ha defense of any Claim or to promptly employ counsel reasonably satisfactory fo thaCounty,then County may
<br /> utilize the Office of the County Counsel or employ separate outside counsel to represent or defend the County, antl I shall pay the
<br /> reasonable attorneys'fees antl costs of such counsel.
<br /> I,furthan certify untler penalty of pa jury that I am(check one):
<br /> � Legal property owner(owner Includes partner,trustee,trustor, or corporate officer)of the property(s)involved in this application, or
<br /> „0� Legal agent(attach proof of the owner's consent to the application oT the properties involved in this application)and have bean
<br /> authoriz'e/d�to/fila on their behalf, and Shat the foregoing application statements era true and correct.
<br /> Print Nama: RGtr�N SlN�'�2n Signature: �� Data: ������z3
<br /> Print Nama: Signature: Data:
<br /> Print Name: Signature: Data:
<br /> Print Nama: Signature: Data:
<br /> Print Name: Signature: Data:
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