THE CORPORATION OF THE CITY OF PORT COQUITLAM
SCHEDULE "Dp" KTVK ‘ Lecayy ¢

APPLICATION FOR LICENCED ESTABLISEMENT RESOLUTION Ga Ge Ss

File No.

Class of Licence Applied For

Applicant's ‘Name:

Address:

Street

Registered Owner:

Address:

Street City Postal Code

Legal Description: Civic Address

Dimensions of property

Proposed use of Property

(Describe new construction planned)

Present Zoning of Property

Proposed Seating Capacity

I/We declare that our interest in the property described above is as follows:

Initials:

Purchaser under Registered Agreement for Sale.

Holder of Registered Option to Purchase.

Holder of

I am the agent of .
holds the interest I have indicated above.

(Date) (Signature)

TO BE COMPLETED BY OFFICE
Non-refundable Processing Fee 490.90

Fee for Newspaper Advertising and Mailing 850.00

(refundable if advertising and mailing not done)
TOTAL FEE PAID 1,250.00

RECEIPT #

DATE