THE CORPORATION OF THE CITY OF FoRT COQUITLAM
SCHEDULE "D"

APPLICATION FOR LICENCED ESTABLISHMENT RESOLUTION

File No. 3

Class of Licence Applied For

Phone:

Applicant's Name:

Address:

Street City Postal. Code

Registered Owner: Phone: |

Address: .
Street City Postal Code

Civic Address

Legal Description:

Dimensions of property ne

Proposed use of Property ;

(Describe new construction planned)

ep ale PP ener: RRS re RR coe

Present Zoning of Property . co | - _

Proposed Seating Capacity . 7

ribed above is as follows:

I/We declare that our interest in the property desc
Initials:

set dept RAE

~ Purchaser under Registered Agreement for Sale.

- Holder of Registered Option to Purchase.

mye one de Tet

- Holder of a ___

who

— I am the agent of
holds the interest I have indicated above.

(Date) | (Signature) | _ a

TO BE COMPLETED BY OFFICE

Non-refundable Processing Fee $ 400.00

S Fee for Newspaper Advertising and Mailing $ 850.00 _
- (refundable if advertising and mailing not done) .
ITEM | PAGE TOTAL FEE PAID $ 1,250.00

a 45 | RECEIPT #

im DATE