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SCHEDULE "A"

"Board of Variance Bylaw, 1981, No. 1919"
(as enacted by Bylaw No. 2615)

BOARD OF VARIANCE APPLICATION

NAME OF OWNER

NAME OF APPLICANT

Cif Different From Oyner)

MAILING ADDRESS

Postal Code

Phone No.

(If Different From Above)

LEGAL DESCRIPTION

(Let) -

ZONING

CURRENT USE

DATE OF PURCHASE

DETAILS OF REFUSAL OR HARDSHIP (Reason for Board of Variance Appeal):

NOTE: | | Signature of Owner

see instructions
on next page

Signature of Applicant
(14f different from owner)

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