(the "Applicant" )

Legal Description of property to be subdivided:

(the "Property")

Civic Address of property:

REZONING: FROM TO Number of Lots Created:

I hereby make application for subdivision of the Property in accordance with
Subdivision Bylaw, 1987, No. 2241, and agree to conform to all requirements of the
said Bylaw and all other statutes and bylaws in force in the City. I herewith
deposit the following non-refundable fees based on the number of lots created in the

attached subdivision plan.

Address to which correspondence is to be sent:

Signed:
Phone Number:
FOR OFFICE USE ONLY
Fees: Examination Fee - = § 25.00
Application Fee - first lot @ $25.00 = $ 25.00
- remaining lots @ $10.00 = £
TOTAL = $
Receipt No:
I, , hereby certify that I am the registered owner of the

(the "Owner")
Property and that I consent to the subdivision of the Property in accordance with

the attached subdivision plan.

Address:

Signed:
(Owner)
Postal Code: Phone No.:
NOTE: This form is to be completed in full and attached to two copies of the

subdivison plan prepared by a B.C. Land Surveyor.

Subdivison File No.: S&