SCHEDULE |

THE CORPORATION OF THE CITY OF PORT COQUITLAM

BYLAW NO. 1298

APPEND! X_"D"

RELEASE, INDEMNIFICATION AND REMOVAL STATEMENT

|, the undersigned, being the registered owner of that certain parce! of land

situate in Port Coquitlam, British Columbia which ig municipally described as:

Street
Address:

and more particularly described as:

Legal
Description:

(the "Lands")

a Plan of Subdivision of which was accepted for deposit at the New Westminster

Land Title Office on the day of » 198 under No.

permit in respect thereof.

(the "Plan't) have made application for a building

In consideration of the City granting my application for 2 building permit for

by the New Westminster Land

+he Lands prior to completion of deposit of the Plan

Title Office, | hereby RELEASE, INDEMNIFY and SAVE the City HARMLESS from and

against any and all claims, actions and losses whatsoever, whether known or

either directly or indirectly, from the

unknown, which nave arisen or may arise,

issuance of this building permit by the City to me.

If the Plan is either rejected or for any reason the deposit of it is not

nths of the date

w Westminster Land Title Office within six mo

completed at the Ne

forthwith thereafter be void

of issuance of the building permit, the permit will