SCHEDULE ‘

"City of Port Coquitlam Waterworks Regulation By-law, 1970, No. 991"
&8 enacted by

“City of Port Coquitlam Waterworks Regulation By-law, 1970, No. 991,
Amendment By-law, 1973, No. 1240"

No.

APPLICATION AND AGREEMENT FOR WATER SUPPLY
I, the undersigned, being the owner (or duly authorized agent) of the
premises described as:

Legal Description

Civic Address Port Coquitlam, B.C.

do hereby make application to have water supplied to the above-described lands

or buildings thereon by a inch service for the following purpose:

Residential (Number of self- : Other than residential
Cy contained housing units to be Cy (Propesed use

supplied with water by this

service: ) )

And I further agree to pay all meter rents and rates for all water
supplied hereunder as prescribed by the "City of Port Coquitlam Waterworks
Regulation By-law, 1970, No. 991" and amendments thereto. I further agree that
I will be bound by all the provisions of the said By-law where applicable, and
the rules, regulations, terms and conditions made thereunder, and in consideration
of the aforesaid I will protect and save harmless The Corporation of the City of
Port Coquitlam from all claims for damages caused by bursting of any pipes,

boilers or tanks er other appliances used for the supply of water under this

application.

Dated at the City of Port Coquitlam this day of
» 19.

Witness: Applicant:

Receipt No. Fee: $

Date Installed: Roll No.: