sii

Mee
“
‘Sy

d the information cont ined
dec h 11 th@ above statements an aine
tn the eaten or ee ot in Support of this application are to the best of my

belief true and correct in ali *espects.

‘ bh; pylaws of the City I may be required to obtain a
bullae weenie in see v0 this Development Variance Permit.

(Applicant's Signature)

(Telephone No.)

I/We consent to the making of tts application:

(Owner's Signature)

(Telephone No,)

te
TO BE COMPLETED BY THE CITY OF PORT COQUITLAM:

Date of Applicatio®

Building Permit RedMired: Yes NO me

. $300.00
Fee Payable: | (refundable if rejected by Council)

$400 .00
(nonrefundable)