THE CORPORATION OF THE CITY OF PORT COQUITLAM
APPLICATION FOR BUSINESS LICENCE

Name of Applicant Pr D ale oes

Dy, os qypo7
Home Address of Applicant — 272262 70S 4n7 677] Likhe

Name and Address of President of Incorporated Company wee DLL.

Trade Name of Business (if any) lA JELLY 6 Sere Oe

Business Address 76.27 KX 6.66 shox oe Liens 3
Det yt3 7

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Business “POS

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Licence applied for wee fF SOO See GC 7?S /. ’

Telephone Numbers: Residence

Number of Persons engaged in business Selling Area

‘Have You held a Licence Before? y: = 3 If so, state when ©

Where: 0 2 2 Es ti fem eee Ce SP IO

Has applicant ever been convicted of any offence of a crimincl nature, or had a previous licence cancelled

or refused: Yes No....4@_. Particulors (if any)

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eos” . . : .

ADDITIONAL INFORMATION TO BE SUPPLIED FOR THE UNDERNOTED LICENCES.

Apartments, Hotels & Auto Courts: No. of Rooms available for rent

Barbers. & Beauty Pariours: No. of Chairs No. of Operators

Pool Rooms & Bowling Alleys: No. of Tables : No. of Alleys

Vending Machines: ic. only machines Other Machines

\/We hereby make application for a licence in accordance with the particulars as above stated and
declare that the above statement is true and correct, and | understand that if | am granted the licence opplied
for, | must comply with each and every obligation contained in all Laws and By-Laws now in force, or which
hereafter come into force in the City. . . to

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f! —?

2 1922 Signature of Applicant
IT 1S AN OFFENCE TO MAKE A FALSE DECLARATION.

CLASSIFICATION:

Approved: _. Fee: $
Licence Inspector (at date of establishing business)

Transfer of Licence No. ......___... No fee required
Date

for period ending _ 19