Hold Harmless Agreement Form Page 2
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1
2Witnesses
�
The following signatures and seals:
�
OWNER and SEAL (Please print name and title):
�
OWNER and SEAL (Please print name and title):
�
FAIRFAX COUNTY, VIRGINIA BOARD OF SUPERVISORS
,
By Director, Site Development and Inspections Division, Land Development Services
Department of Public Works and Environmental Services
STATE OF:
COUNTY OF:
I
a Notary Public in and for the County and State aforesaid,
Whose commission expires on the
of
20
do hereby certify that
name(s) is/are signed to the
foregoing Agreement bearing date of the
of
20
has acknowledged the same before me in my said County and State.
GIVEN UNDER M Y HAND this
of
20
Notary Public
STATE OF:
COUNTY OF:
I
a Notary Public in and for the County and State aforesaid,
Whose commission expires on the
of
20
do hereby certify that
name(s) is/are signed to the
foregoing Agreement bearing date of the
of
20
has acknowledged the same before me in my said County and State.
GIVEN UNDER M Y HAND this
of
20
Notary Public
Project #
TAX MAP #
Updated Feb 2015
Page 2 of 2
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