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THE CORPORATION OF THE CITY OF PORT COQUITLAM
"SOIL REMOVAL REGULATION BYLAW NO. 2666"

DECLARATION

PERMIT NO. EXPIRY DATE

PERMIT FEE PAID based on cubic metres.

$ AMOUNT ENCLOSED ($.10 per cubic metre in excess of quantity
specified in permit)

CANADA ) IN THE MATTER OF THE CITY OF PORT
PROVINCE OF BRITISH) COQUITLAM SOIL REMOVAL BYLAW NO. 2666,
COLUMBIA ) 1992, AND PERMIT NO ’

I,

(permit holder)

of

(addrega)

IN THE PROVINCE OF BRITISH COLUMBIA DO SOLEMNLY DECLARE THAT:

lL. I am the

(Owner, Lessee, Signing Officer of Limited Company)

of

(addreas )
That I have personal knowledge hereinafter deposed.

I hereby declare that during the period
to | the volume of soil removed from
the lands deacribed on Permit Number issued
te . on the day of in
the year WAS cuble metres.

AND I made the solemn declaration conscientiously believing it to be true, and
knowing that it is of the same force and effect as if made under oath and hy
virtue of the Canada Evidence Act.

‘DECLARED BEFORE ME at

in

the Province of British
Columbia this day of
a

)
A Notary Public in the )
Province of British Columbla )
A Commissioner for taking )
Affidavits for British Columbia)

THIS DECLARATION MUST BE SUBMITTED TO THE CITY OF PORT COQUITLAM WITHIN ONE
MONTS Ct THE EXPIRY OF A SOIL REMOVAL PERMI