Application for Consent

Under Section 53 of the Planning Act
Ontario Regulation 197/96

All questions must be completed, or the application will be deemed incomplete and will not be accepted.

Applicants must pre-consult with the Municipality; the submission of this form does not imply Municipal support or approval for the application

1. Registered owner(s):

Address:

City/Town:

Postal code:

Email:

Primary form of contact?

Yes

Phone:

Alternate:

Fax:

Name of applicant(s) differs from above.

Name of applicants:

Address:

City/Town:

Postal code:

Email:

Primary form of contact?

Yes

Phone:

Alternate:

Fax:

Owners use an authorized agent.

Name of authorized agent:

Address:

City/Town:

Postal code:

Email:

Primary form of contact?

Yes

Phone:

Alternate:

Fax:

Please specify the person to be contacted if more information is required. All communications, including the poster, will be directed to this person:

Registered owner(s)

Applicant(s)

Authorized agent

Is the Registered Owner, Applicant or Authorized Agent applying for additional consents simultaneously with this application?

Yes

Important: The owner’s authorization, page 7 of 9 of this application form, is required if the application is submitted by a person, or persons, other than the registered owner(s).

2. (a) Type and purpose of proposed transaction: (please check appropriate box)

(b) If known, the name of the person(s) to whom the land, or an interest in the land, is to be transferred, charged or leased:

3. Location of subject land(s)

Municipality:

Geographic township / village:

Concession number(s):

Lot number(s):

Registered plan no.:

Lot(s) / block(s):

Reference plan no.:

Part number(s):

Are there any easements or restrictive covenants affecting the subject land?

Yes

If yes, describe the easements or covenant and its effect:

4. Description of lot to be severed:

Frontage: metres

Depth: metres

Area: metres²

Existing use:

Proposed use:

Number / use of existing buildings / structure:

Proposed use for severed lot:

5. Description of lot to be retained:

Frontage: metres

Depth: metres

Area: metres²

Existing use:

Proposed use:

Number / use of existing buildings / structure:

6. Type of access: (check appropriate space)

Access type	Severed lot	Retained lot
Provincial highway	severed	retained
County road	severed	retained
Municipal road (maintained year round)	severed	retained
Municipal road (seasonally maintained)	severed	retained
Private road	severed	retained
Right-of-way / easement	severed	retained
Water access (specify parking/docking facilities)	severed	retained

7. Type of water supply proposed or existing? (check appropriate space)

Water supply type	Proposed	Existing	Proposed	Existing
Municipally owned/operated piped water system	Proposed	Existing	Proposed	Existing
Privately owned and operated individual well	Proposed	Existing	Proposed	Existing
Privately owned and operated communal well	Proposed	Existing	Proposed	Existing
Lake or other water body	Proposed	Existing	Proposed	Existing
Not required	Proposed	Existing	Proposed	Existing

If proposed, when will services be available?

8. Type of sewage disposal system proposed or existing? (check appropriate space)

Type of system	Proposed	Existing	Proposed	Existing
Municipally owned/operated sanitary sewers	Proposed	Existing	Proposed	Existing
Privately owned/operated individual septic system	Proposed	Existing	Proposed	Existing
Privately owned/operated communal septic system	Proposed	Existing	Proposed	Existing
Pit privy	Proposed	Existing	Proposed	Existing
Not required	Proposed	Existing	Proposed	Existing

If proposed, when will services be available?

9. What is the existing Official Plan designation(s) of the subject land?

Designation:

This application relates directly to an Official Plan amendment(s) currently under review by an approval authority.

Amendment number(s):

File number(s):

10. All lands are covered by a Zoning By-law; indicate what the Zoning is for the subject lands:

Zoning:

Is the area under discussion the subject of an application for a Zoning By-law Amendment, Minor Variance or approval of a Plan of Subdivision?

Yes

Unknown

File number:

Status:

11. Is there an agricultural operation (including an abattoir, livestock or stock-yard) within 500 meters?

Yes

Type of operation:

12. Is there a landfill within 500 meters?

Yes

13. Is there a sewage treatment plant or waste stabilization plant within 500 meters?

Yes

14. Is there a Provincially and/or locally significant wetland (e.g., swamp, bog, etc.) located on the lands to be severed or retained or within 120 meters?

Yes

15. Is any portion of the land to be severed or retained located within a flood plain?

Yes

16. Is there a Provincial Park or Crown Lands located within 500 meters?

Yes

17. Is there an active, or inactive, mineral extraction site (Pit and/or Quarry) within 500 meters?

Yes

18. Is there an active principal, or secondary, main line Railway within 500 meters?

Yes

19. Is there an Airport or Aircraft landing strip nearby?

Yes

If yes, please specify:

Federal

Provincial

Local

Distance to your holdings: metres

20. Is the property within a Municipal drinking water Vulnerable Area as defined in the Clean Water Act?

Yes

21. Does this application conform to the 2014 Provincial Policy Statement?

Yes

23. Is this a re-submission of a previous application?

Yes

If yes, is the application:

Identical

Changed

24. Has the present owner previously severed any land from this holding?

Yes

Provide previous severances on the sketch and give the following information for each lot severed:

Grantee's name:

Date parcel created:

Use of parcel:

File number (if known):

25. Has the subject land ever been, or is it now, the subject of an application for a Plan of Subdivision under Section 51 of the Planning Act, or its predecessors?

Yes

Please provide the following information:

File number:

Date of final approval:

26. Other Information

An explanation as to the reason and purpose for this severance must be provided or the application will be deemed to be incomplete.

Explanation for severance:

27. Required Sketch – the application must be accompanied by a sketch showing:

The boundaries and dimensions of the subject land;
The boundaries and dimensions of any land abutting the subject land that is owned by the owner of the subject land;
The distance between the subject land and the nearest township lot line or landmark, such as a railway crossing or bridge;
The location of all land previously severed from the parcel originally acquired by the current owner of the subject land;
The approximate location of all natural and artificial features on the subject land, and adjacent land, that in the opinion of the applicant may affect the application, such as buildings, railways, roads, watercourses, drainage ditches, river or stream banks, wetlands, wooded areas, barns, wells and septic systems;
The location, width and name of any roads within, or abutting, the subject land, indicating whether it is a Provincial highway, County Road, an unopened road allowance, a public traveled road, a private road or a right-of-way;
If access to the subject land is by water only, the approximate distance of the parking and docking facilities from the subject land and the nearest public road; and
The location and nature of any easement affecting the subject land.

“Subject Land” means the land to be severed and the land to be retained

Please see sample sketch (PDF)

28. Authorization

If the applicant is not the owner of the land that is the subject of this
application, the written authorization of the owner that the applicant is authorized to make this application on their behalf must be included with this form or alternatively the authorization, as set out below, must be completed by the Registered Owner(s):

I/We being the Registered Owner(s) of the land(s) that are the subject of this Application for Consent, hereby authorize the Applicant to prepare and submit this application on my/our behalf.

29. Permission to access property

I hereby authorize and consent to permit municipal and Conservation Authority staff to enter upon the subject property during regular business hours during the time that the application is under consideration by the Counties of Stormont, Dundas and Glengarry for the purpose of conducting site inspections.

30. Sworn declaration

I/We, as the Registered Owner(s), Applicant, or Authorized Agent do solemnly declare that all the statements contained in this Application for Consent for the above property and all supporting documents are true, and I/We make this solemn declaration conscientiously believing it to be true and complete, and knowing that it is of the same force and effect as if made under oath, by virtue of the “Canada Evidence Act”.

31. Freedom of information

I hereby acknowledge and provide my consent, in accordance with the provisions of the Municipal Freedom of Information and Protection of Privacy Act, that the information on this application and any supporting documentation provided by myself, my agents, consultants and solicitors, will be part of the public record and will also be available to the general public.

Alerts

Application for Consent

Additional Information