HomeMy WebLinkAbout2022 Committee of Adjustment - Application for Consent2022 Page 1 of 8
(Section 53 of the Planning Act)
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Planning Division 200 King Street West, 6 Floor
P.O. Box 1118, Kitchener ON N2G 4G7
519-741-2426; planning@kitchener.ca
Office Use Only:
SUBMISSION NUMBER: B (to be assigned by staff)
1. ADDRESS OF SUBJECT PROPERTY:
Have you previously consulted with staff on this application?
If yes, name and date of consultation:
Date Stamp
2. FOR YOUR INFORMATION:
It is recommended to consult with staff prior to submitting your form. Applications will not be accepted as
complete unless all legislated requirements have been met and will not be processed until all necessary
information has been provided.
Committee of Adjustment is a public process. Applications will be circulated to public agencies for
comment. Notice of the meeting will be circulated to property owners within 30 metres of the subject
property, advertised in the local newspaper and a City-issued notification sign posted on the property. All
parties are given the opportunity to provide written comment or attend the meeting, either in support or
opposition of the application, or to appeal a subsequent decision of the Committee of Adjustment.
In addition to the submission requirements found on the application form, it is imperative that the applicant
provide all the planning evidence necessary in support of the request being made. Depending on the
nature of the application, this evidence may be in the form of photographs showing the existing
streetscapes, contextual plans (in context with adjacent structures), historical information and/or detailed
location plans (windows, openings, accessory structures) of the abutting properties. This will assist the
Committee in making an informed decision regarding your application.
The owner and/or agent must attend the Committee meeting in support of their application. Information
on the meeting date/time will be forwarded to the applicant. A deferral fee will apply on applications
requiring re-circulation for failure to attend meeting or requesting postponement.
This is YOUR application - make sure that you know the exact details of why you are applying. You must
identify exactly what is being requested, particularly as it relates to easements, rights-of-way or partial
discharge of mortgage. It is your responsibility to provide a complete and accurate application. Staff are
available for consultation, but they are not permitted to complete the form on your behalf.
3. SUBMISSION REQUIREMENTS:
Complete applications shall be submitted by email to planning.applications@kitchener.ca (maximum 10 MB).
Original, signed & commissioned application form, including plans, and cheque (payable to the City
of Kitchener) must be delivered to City Hall - Planning Division, Attention: Manager of Development Review,
within one week of the digital submission deadline (you may send by mail, courier or drop off in person).
Application form (completed and signed)
Written authorization of the owner(s) is required if the application is signed by an agent on their behalf.
2022 Page 2 of 8
Affidavit notary or lawyer
(if you require commissioning services, please make an appointment with City staff at:
https://outlook.office365.com/owa/calendar/CityofKitchenerServiceCounters@kitchener.ca/bookings/
- )
Detailed sketch completed by an Ontario Land Surveyor (O.L.S.) is required. The plan cannot
exceed 11 x 17 in size and must be folded to letter size and submitted with the application. Please
note the severance sketch sample on page 5 of this application
Completed Environmental Site Screening Questionnaire
If the site is located within a Source Protection Area, provide a copy of the Notice of Source Protection Plan
Compliance (Section 59 Notice) obtained from the Regional Municipality of Waterloo. For more information,
http://www.regionofwaterloo.ca/sourceprotection
Application fee of $1,553.00 (non-refundable)
Note: A fee is required for each new lot created. A regional processing fee also applies, which may be
submitted with this application form by separate cheque, payable to the Region of Waterloo, which will
be forwarded on your behalf.
website - Region of Waterloo - Development Application Fees
4. REGISTERED OWNER(S)
Name(s): Phone:
Company (if applicable): Extension:
Street Address: Email:
City/Province: Postal Code:
5. AUTHORIZED AGENT (if different from registered owner)
Name(s): Phone:
Company (if applicable): Extension:
Street Address: Email:
City/Province: Postal Code:
6. PROPERTY INFORMATION
a) Street Address:
Closest Intersection:
Legal Description (from Survey or Plan):
Lot(s) No: Registered Plan No.:
Lot(s) No: Reference Plan No.:
Part(s) No:
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b) Type of Road Access: Public Private
c) Municipal services available:
Water: Yes No Sanitary Sewer: Yes No
Storm Sewer: Yes No Private Well: Yes No
Septic: Yes No
7. 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 purpose of your application:
b) Does this proposal require a minor variance application? Yes No
c) Are there any easements or restrictive covenants affecting the subject property? Yes No
If yes, please describe the easement or covenant and its effect:
8. DESCRIPTION OF REQUEST
Development Standard Required Severed Retained
Lot Width
Lot Depth
Lot Area
Existing Use(s) of Land
Proposed Use(s) of Land
# of Existing Buildings/Structures
# of Proposed Buildings/Structures
Use(s) of Buildings/Structures
Number of New Lots Proposed (not including retained lot):
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9.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 (District) Easement/Agreement
e) Does the property have any significant environmental features: Yes No
If yes, indicate: Woodlot Wetland Valleyland Other:
f)Has the owner previously severed any land from this holding? Yes No
If yes, please indicate submission no.:
If yes, also indicate previous severance(s) on the required sketch and supply the following information
for each lot severed:
Transferee Name:
Relationship to the owner (if any):
Use of Parcel:
Date Parcel was created:
Date of acquisition by current owner:
g) Is the owner applying for additional consents on this holding simultaneously with this application, or
considering applying for additional consents in the future? Yes No
h) Is this application consistent with the Provincial Policy Statements issued under subsection 3(1) of the
Planning Act R.S.O. 1990, Chapter P.13, as amended? Yes No
i) Is the subject land affected by the Growth Plan or Growth Plan Policies? Yes No
If yes, does this application conform to, or not conflict with, the applicable provincial plan or plans?
Yes No
j) Certificate Request for Retained Lands: Yes No
* If yes, a statement is required from an Ontario solicitor in good standing that there is no land abutting the subject
land that is owned by the owner of the subject land other than land that could be conveyed without contravening
section 50 of the Act. (O. Reg. 786/21, s. 1 (2)).
k) Is there any other information that you think may be useful to the City, Region or other agencies in
reviewing this application? Please explain:
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10. DETAILED SKETCH
It is very important to be as accurate as possible, as any deficiencies may delay consideration of your
application. Survey must be an original (not a photocopy) - plan must be drawn to scale by an Ontario Land
Surveyor (O.L.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
application.
The location and nature of any easement affecting the subject lands.
The size, location and type of all existing and proposed buildings, structures or additions on the subject
land, measured from the front, rear and side lot lines.
The location of all driveways and parking spaces.
The location, width and name of any roads within or abutting the subject land.
Identify any natural features on the subject land (trees, streams, etc.).
SAMPLE SKETCH:
2022 Page 6 of 8
11.REGIONAL MUNICIPALITY OF WATERLOO -ENVIRONMENTAL SITE SCREENINGQUESTIONNAIRE
On behalf of the Regional Municipality of Waterloo, this form must be completed for all development applications
submitted to the City of Kitchener.
1. What are the current uses of the property?
2. Was the subject property ever used for industrial purposes? Yes No Uncertain
If yes, please describe approximate dates and types of industry:
3. Was the subject property ever used for commercial purposes where there is potential for site construction
(i.e. automotive repair, gas station, dry cleaning operation, chemical warehousing, etc.)?
Yes No Uncertain
If yes, please describe approximate dates and types of commercial activity:
4. Has waste (garbage, solid wastes, liquid wastes) ever been placed on this property?
Yes No Uncertain
If yes, when?
Please provide description of waste materials:
5. Have hazardous materials ever been stored or generated on the property (e.g. has HWIN registration or
other permits been required)? Yes No Uncertain
If yes, please summarize details:
6. Is there reason to believe that this property may be potentially contaminated based on historical use of
this or an abutting property? Yes No Uncertain
If yes, please describe the nature of the suspected contamination:
7. Has the subject property or adjacent property ever been used as an agricultural operation where cyanide
products may have been used as pesticides? Yes No Uncertain
8. Are there or were there ever any above ground or underground storage tanks for fuels or chemicals on
the property? Yes No Uncertain
If yes, please summarize details:
9. Does this property have or ever had a water supply well, monitoring well, geothermal well?
Yes No Uncertain
If yes, please provide details:
10. Does the property use or has it ever used a septic system? Yes No Uncertain
11. Have any environmental documents been prepared or issued for this property, including but not limited to
a Phase I and II environmental site assessment, risk assessment, Record of Site Condition or Certificate
of Property Use? Yes No Uncertain
12. Will lands be dedicated to the Region as part of this application (including road allowances, daylight
triangles?) Yes No Uncertain
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12.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.
Signature of Owner: Date:
Signature of Owner: Date:
13. ACKNOWLEDGEMENT
I understand that receipt of this application by the City of Kitchener - Planning Division does not guarantee it
provide additional information and/or resolve any discrepancies or issues with the application as submitted.
Once the application is deemed to be fully complete, the application fee will be deposited and the application
will be processed. Submission of this application constitutes consent for authorized municipal staff to enter
upon the subject property for the purpose of conducting site visits, including photographs, which are
necessary for the evaluation of this application.
I further acknowledge that a City-issued notification sign must be posted at the front of the subject property
in a location that is visible from the street. Staff will advise when to post the sign and it shall remain in place
for 20 days after the Committee decision has been issued.
Signature of Owner or Agent: Date:
14. 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 virtue
of the Canada Evidence Act.
Signature of Owner/Agent Signature of Owner/Agent
Declared before me at the
Town/City of in the County/Regional Municipality of
This day of , 20 .
Signature of Commissioner of Oaths
*Commissioner/Notary please affix stamp
*Lawyer please print name beside signature