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SCHEDULE @

PLUMBING PERMIT, TYPE: ON-SITE SERVICES

APPLICATION DATE PERMIT NO.

This permit is issued to the Qwner named below, for the purpose of the
plumbing or related work described herein. The validity of this permit is
subject to compliance with the plans and other documents submitted with
the permit application, and to the compliance with the "Port Coquitlam
Building and Plumbing Bylaw".

DESCRIPTION OF WORK ;

ADDRESS ;

LOT PLAN ZONING

OWNER CONTRACTOR

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Name Name

Address Address

City City

Postal Code Telephone Postal Code Telephone

SIGNATURE OF NAME
OWNER/ AGENT TELEPHONE

NOTES

PERMIT FEES:

On-Site Services Manhole(s)
Interceptor(s)
Catch Basin(s)
Lawn Drain(s)

Water Main Metres of Pipe
Sanitary Sewer Metres of Pipe
Storm Sewer Metres of Pipe
Fire Hydrant Fire Hydrant(s)
Other Specify

TOTAL FEES: sssnraeestssmssscsss

THE ISSUANCE OF THIS PERMIT SHALL IN NO CASE BE TAKEN AS ASSUMPTION OF
RESPONSIBILITY BY THE CITY FOR ERRORS OR VIOLATIONS OF CODES, STATUTES OR

BYLAWS

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