SCHEDULE "6"

THE CORPORATION OF THE CITY OF PORT COQUITLAM
(the "City")

CONSENT, RELEASE AND INDEMNITY

Name: Dates
(the Applicant”)

Address of the Property on which work is requested:

(the "Property"

fne Problem on the Property:

(the "Problem")

The Work Requested is:

WHEREAS the Applicant is the registered owner in fee simple of the Property or is
the authorized agent cf the registered owner, and the Applicent has requested that
the City solve the Problem and the Applicant consents to the City entering the
Property with men and equipment in order to asseaa the Problem and to take such

action as the City considers advisable;

NOW THEREFORE in consideration of any action taken by the City in regard to
assessment and correction of the problem:

1. The Applicant covenants and agrees with the City that the Applicant will:

a- indemnify and save harmless the City from all loss, damage, costs, actions and
suits which the City may suffer or incur er be put to; and

6. remise, release and forever discharge the City from and against all manner of
actions, causes of action, claims, debts, demands and promises of any kind which the
Applicant now has or at any time hereafter may have

arising out of or in cennection with assessing the Problem and actions taken to
correct the Problem.

2. The Applicant covenants and agrees that in the event the source of the Problem
is not within the City's scope of responsibility then the Applicant will on demand
From the City promptly reimburse the City for any costs and expenses it incurs in
assessing the Problem and in acting to correct the Problem.

3. .This Agreement is binding upon the Applicant and his respective successors and
assigns, and every reference in this Agreement ta the Applicant and the City
includes where the context so requires the officers, employees, agents, servants,
successors and assigns of each; and wherever the singular or masculine is used the
same shall be deemed to be the feminine, the plural or the body politic or corporate
as the context so requires; and the release and indemnification is binding
notwithstanding any rule of law or equity to the contrary; and in the event the
Applicant is not the registered owner of the Property the Applicant covenants and
agrees that the indemnification and release set out above binds the Applicant
personally and also binds the registered owner of the Froperty.

IN WITNESS WHEREOF having first read and fully understanding this Agreement and with
the knowledge end understanding that the release constitutes a final and irrevocable
settlement of all my claims as aforesaid and that the indemnity constitutes my
agreement to reimburse the City for damages and costs as aforesaid, [ have hereunto
set my hand on the day first written above.

SIGNED by the Applicant in the  )
Municipality of Port Coquitlam in)
The Province of British Columbia )
in the presence of: ,

Name Signature of Applicant

Address

Signature of Witness

ee re we

Occupation

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