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I hereby declare that all the above statements and the informacion contained
in the material submitted in support of this application are to the best of my

belief true and correct in all respects.

I understand that under the bylaws of the City I may be required to obtain a
building permit in addition to this Development Variance Permit.

(Applicant's Signature)

(Telephone No.)

I/We consent to the making of this application:

(Owner's Signature)

(Telephone No.)

TO BE COMPLETED BY THE CITY OF PORT COQUITLAM

Date of Application

Building Permit Required: | Yes No

Fee Payable: $300 .00
(refundable if rejected by Council)

$400 .00
(non~-refundable) .