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

*

wx ah eK aR wR HR we Ow Re we ew RK

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