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SCHEDULE _"

"City of Port Coquitlam Board of Variance By-law, 1969, No. 931"

as enacted by
Amendment By-law No.i243 .

BOARD OF VARIANCE APPLICATLON

Date

Name

Maiding Address Phone No.

Address of Property (Please ensure thit
this address is

marked on the property)

Legal Description

Zoning

Current Use of Property

Proposed Use of Property

Date of Purchase

Section of Municipal Act Under Section of Municipal By-law on
Which Appeal ia Being Made Which Appeal is Being Made

se,

Snetataa

Details of Refusal or Hardship

(See Second Page)
Signature of Ower