THE CORPORATION OF THE CITY OF PORT COQUITLAM
SCHEDULE "“D”
APPLICATION FOR LICENCED ESTABLISHMENT RESOLUTION

File No.

Class of Licence Applied For

Applicant's Name:

Address:

Postal Code

Registered Owner:

Address:

Street City Postal Code

Legal Description: Civic Address

Dimensions of property

Proposed use of Property

(Describe new construction planned)

Present Zoning of Property

Proposed Seating Capacity

I/We declare that our interest in the property described above is as follows:
Initials:

Purchaser under Registered Agreemert for Sale.

Holder of Registered Option to Purchase.

Holder of

I am the agent of
holds the interest I have indicated above.

(Date) (Signature)

Feenstra gregh
TO BE COMPLETED BY OFFICE
Non-refundable Processing Fee $ 400.00

Fee for Newspaper Advertising and Mailing $ 850.00
(refundable if advertising and mailing not done)
TOTAL FEE PAID $ 1,250.00

ITEM | PAGE

35°

RECEIPT

DATE