COMMITTEE OF ADJUSTMENT APPLICATION FOR CONSENT

TYPE AND PURPOSE OF THE APPLICATION Conveyance: Creation of Lot (fee required for each new lot created + Regional fee as noted above) Addition to a Lot Validation of Title Other Name of persons (purchaser, lessee and mortgagee) to whom the land or interest in lands is intended to be conveyed: Other: Mortgage Lease Easement/Right-of-Way a) Please provide an explanation summarizing the. [...] PLANNING INFORMATION a) Official Plan designation: Zoning Category: b) Has the land previously been the subject of a consent or plan of subdivision? Yes No If yes, describe: c) Is the subject property currently undergoing Site Plan Approval: Yes No d) Does the property have any Heritage Status: Yes No If yes, please check below: Inventory Listed Part IV (Individual) Part V (Distr. [...] S.) and show the following information: The boundaries and accurate dimensions of the subject land It is mandatory to clearly label the lands to be severed (outlined in red) and the lands to be retained (outlined in green) – dimension must match the information contained in the application The plan cannot exceed 11 x 17 in size and must be folded into letter size and attached to each applica. [...] AUTHORIZATION If this application is being made by an agent that is not the owner of the subject lands, written authorization of the owner is required, as below: I/we, , owner(s) of the land that is the subject of this application, hereby authorize to act on my/our behalf in regard to this application. [...] AFFIDAVIT (to be completed in person in the presence of a Commissioner of Oaths) I/we, , of the Town/City of , in the County/Regional Municipality of , solemnly declare that all of the above statements contained in this application are true and I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath and by vir.