SCHEDULE A

APPLICATION FORM FOR A BUILDING PERMIT

APPLICATION DATE:

I hereby make application under the Port Coquitlam Building and Plumbing
Bylaw for permission to construct, repair or alter the following building
or structure and agree to comply with all the requirements of the said
Bylaw and to indemnify and keep harmless the Municipality against ali
claims, liabilities, judgements, costs and expenses of whatever kind,
which may in any way accrue against the said municipality in consequence
of, and incidental to, the granting of the Permit, if issued.

BUILDING SITE ADDRESS:

PARTIAL LEGAL DESCRIPTION: Lot #

OWNER

Address

ty City

Postal Code Postal Code Telephone

PROPOSED WORK

New _ Add__ Renovate Use of Proposed
Building:

Estimated Construction Value:
$ Occupancy
Use:

Existing Buildings on Lot?

wk KR eK OR He eR wR en HR Every owner shall give at least 48
*OFFICE USE ONLY hours notice to a Building
* Inspector prior to the start of
*Permit No.: work on the building site.

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& £ ¢

APPLICANT

*Zoning:
*

*Processing Fee Paid:
*

to.
*Receipt No.:
ke

% * &£ & © & & 8 F F

-*Comments: Signature

*

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ah eK aR wR HR we Ow Re we ew RK

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