CITY OF PORT COQUITLAM
APPLICATION FOR LICENCED ESTABLISHMENT ee

FILE NO:

TO BE COMPLETED BY APPLICANT — Please print clearly

ee,
Applicant's Name Registered Owner |
“ - Address Address .
, (include postal code) (include postal code ) : -
Phone Number Phone Number |
Legal Description of Property
; -_
Civic Description of Property oe
Proposed Use of the Property | a
i (Describe New Construction Planned) ” i
- . Size of Property : 1s
* Z I/We declare that our interest in the Property described above is as follows:
- Registered Owner of Purchase under Registered Agreement for Sale ;
~ Holder of a Registered Option to Purchase ! .
~ Holder of ;
| ~ Iam the agent of who holds the | |
interest I have indicated above. fo. :
(Date) (Signature) : :
TO BE COMPLETED BY OFFICE : _
Non-refundable processing fee $ 400.00 a |
Fee for newspaper advertising and $ 850.00 | 2
mailing (refundable if Public :
Information Meeting :
is not held). TOTAL FEE PAID $ __1250.00 Pos
RECEIPT # De

ID23(1)