APES teeta:

THE CORPORATION OF THE CITY OF PORT COQUITLAM

‘SCHEDULE *
_ APPLICATION FOR LICENCED ESTABLISHMENT RESOLUTION —

_. Glass of Licence Appited For.

Applicant's Namez Phone: _

oC adaréess é OE ue : : eae ee ©
pe ta _ Street Sy cs Postal Cede

Phone:

"Legal Deseription:

“Dimensions of property __

(beseribe 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: | CTE ag ae

- Purchaser under Registered Agreement for Sale.

Holder of Regist red Option to Purchase. ©

Holder of

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

— (Signature)

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

RECEIPT #

DATE
{TEM | PAGE