Township of North Stormont

Entrance Permit Application

LANDOWNER'S NAME _______________________

APPLICANT (if different than Landowner)______________________________

ADDRESS___________________________________________

TELEPHONE #_____________FAX #_____________________

LOCATION Civic #_______Road Name____________________

Side of Road (Circle)--North--South--East--West
Municipality Finch / Roxborough LOT____ CON._______
LAND PARCEL #___________
Located_______Meters From (circle)----North--South--East--West---of ______________________(prominent features: lot line, utility pole, tree, etc)
Marked by a, ----Stake----Paint--or,______________________

PURPOSE OF APPLICATION This Application is for, ----New Entranceway, ---YES----NO

An alteration or change in use of an existing entranceway----YES----NO
NOTE: Relocation of an entranceway is considered a NEW ENTRANCEWAY

CLASSIFICATION OF ENTRANCEWAY
    --Residential--Commercial--Agricultural--
Zone Classification--Rural--Urban----
If no change in use, former classification
    --Residential--Commericial--Agriculture

THE CONSTRUCTOR: Shall be responsible for obtaining Public Liability and Property Damage Insurance of a minimum $ 2,000,000.00. Shall work in accordance with Occupational Health and Safety Act, "Construction Regulation", also be in accordance with the Township of North Stormont By-Law # 020-02, "Construct an Entranceway".

CONTACT PERSONS:

Blake Henderson, Cell 551-0498 Fax 984-2908

Alain Sabourin, Cell 551-1502 Fax 538-2199