SCHEDULE A

APPLICATION FORM FOR A BUILDING PERMIT

APPLICATION DATE:

I hereby make application under the

Bylaw for permission to construct,

Port Coquitlam Building and Plumbing
epair or alter the following building

or structure and agree to comply with all the requirements of the said
Bylaw and to indemnify and keep harmless the Municipality against all

claims, liabilities, judgements,

costs and expenses of whatever kind,

which may in any way «accrue against the said municipality in consequence
of, and incidental tv, the granting of the Permit, if issued.

BUILDING SITE DRESS:

PARTIAL WEGAL DESCRIPTION: Lot #

OnaER

Address

City

Postal Code Telephone
PROPOSED WORK

New: ~ Add Renovate.

Estimated Construction Value:
$

Existing Buildings on Lot?

eR wk we we ww
kOFFICE USE ONLY

*

kPermit No.:
k

xZoning?
*

*Processing Fee Paid:
*

Receipt No.:
te

*Comments:

Address

City

Postal Code Telephone

Use of Proposed
Building:

Occupancy
Use:

Every owner shall give at least 48
hours notice to a Building
Inspector prior to the start of
work on the building site.

APPLICANT

Signature

ITEM

Telephe