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SCHEDULE _M

ASSURANCE OF SUBSURFACE INVESTIGATION
To be submitted prior to issuance of a building permit.

Date:

City of Port Coquitlam
Building Department
2580 Shaughnessy Street
Port Coquitlam, BC

V3C 2A8

ATTENTION: Director of Building Permits and Inspections

Dear Sirs:

RE: Legal Description:
(the "Property")

Owner
Address
Building Permit Application No.
(the "Project")

The undersigned gives assurance that I have carried out a subsurface
investigation in respect of the Project on the Property in accordance with
Part 4, Section 4.2.4, of the B.C. Building Code. Further, the
undersigned gives assurance, that:

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(a) the subsurface conditions of the Property are consistent
with the plans and supporting documents, including all
amendments submitted with the application for a building
permit; and

the Property has been prepared in accordance with
recommendation outlined in the soils report prepared
by '
dated , in accordance with
Section 734(4) of the Municipal Act.