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THE CORPORATION OF THE CITY OF PORT COQUITLAM
"SOIL DEPOSIT REGULATION BYLAW NO. 2665”

SGHEDULE “D"

DECLARATION

PERMIT NOQ. 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 DEPOSIT BYLAW NO
COLUMBIA 2665, 1992, AND PERMIT NO ’

I,

(permit holder)

of

(address)
IN THE PROVINCE OF BRITISH COLUMBIA DO SOLEMNLY DECLARE THAT:

[ am the

(Owner, Lessee, Signing Officer of Limited Company)

of

(Address )
That I have personal knowledge hereinafter deposed.
I hereby declare that during the period to

the volume of soil deposited on the lands described on Permit Number

issued to on the day of

year cubic metres.