Submission No:
Planning Approvals 100 Regina Street South P.O.
Box 337, STN. Waterloo, Waterloo, ON N2J 4A8
Ph: 519-747-8752 | Fax: 519-747-8523
Have you consulted with City staff prior to submitting this application?
Date of consultation:
Name of City staff member consulted:
Is your application required to go through the Site Plan Review committee process?
If yes: Date of Site Plan pre consultation meeting:
Date of most recent Site Plan meeting where support
for the site’s ability to function was obtained:
Support from the Site Plan Review Committee does not determine staff support with respect to this
Committee of Adjustment Application.
Does your application include complete and accurate drawings?
Have you included 2 copies of this application form plus the original copy?
Have you included the correct fee?
Have you completed the owner consent, owner authorization & declaration sections?
Signature of Applicant/Authorizing Agent Date
Submission No:
Planning Approvals 100 Regina Street South P.O. Box
337 Stn. Waterloo, Waterloo, ON N2J 4A8
Ph: 519-747-8752 | Fax: 519-747-8523
The undersigned hereby applies to the Committee of Adjustment for the City of Waterloo under Section 45 of the Planning Act,
R.S.O. 1990, Chapter P.13 for relief, as described in this application from By-law No. 1108, 1418 or 878A (circle one).
Name of the Registered Owner(s):
Mailing Address:
City: Postal Code:
Telephone Number: Fax Number:
Email Address:
Name of Authorized Agent(s):
Mailing Address:
City: Postal Code:
Telephone Number: Fax Number:
Email Address:
Note: Unless otherwise requested, all communications will be sent to the agent.
Location of Property
Street Address:
Legal Description (from survey or plan)
Lot(s) No: Registered Plan No:
Lot(s) No: Registered Plan No:
Lot(s) No: Registered Plan No:
Nature and extent of relief applied for:
In your personal opinion, why is it not possible to comply with the provision of the by-law?
Present Official Plan designation applying to the land
resent Zoning category applying to the land
Has the owner previously applied for relief in respect of subject property? Yes No
If the answer is yes, describe briefly:
Is the subject property the subject of a current application for consent under Section 53 of the Planning Act?
(i.e., severance creation of new lot) Yes No
oning Review (in metres)
equired Proposed
Lot Frontage
Lot Depth
Lot Area
Front Yard Setback
Side Yard Setback
Flankage Yard Setback (if a corner lot)
Rear Yard Setback
Coverage %
Landscape Open Space Requirement
Accessory Building Setback
(if required)
Particulars of all buildings and structures on or proposed for the subject lands:
Existing Proposed
Ground Floor Area (incl. Garage)
Gross Floor Area
Number of Storeys
When did you purchase this property?
Date of construction of all buildings and structures on subject land:
Existing uses of subject property: (type and use)
Proposed use of subject property:
Existing uses of abutting properties:
Length of time the existing uses of the subject property have continued:
(How long has this use been occupying this property?)
Municipal services available? Water Yes No Connected? Yes No
Sanitary Sewers Yes No Connected? Yes No
Storm Sewers
Type of road access/road name:
Yes No Connected? Yes No
Application Requirements
1) 2 copies of this application form plus the original copy.
2) Authorization Form signed by registered owner(s).
Application fee in cash or cheque made payable to the Treasurer of the City of Waterloo.
8 copies of maximum 11”x17” size plan(s):
Plan of survey, up to date and prepared by an Ontario Land Surveyor
Site Plan, indicating type, size and location of existing and proposed building(s) on the site, distance
from all lot lines, location of any easement/rights-of-way, location of buildings on adjacent lots,
roads etc.
Elevation Plans, for all sides where new construction is proposed and indicating height, grade and
window and door openings
Floor plans, all rooms labeled as to use and indicating existing and proposed windows and
Location of natural and artifical features (eg. railways, roads, water courses, wetlands, wooded
areas, etc)
Use of adjacent property(s).
General Requirements for All Plans:
Metric scale and dimensioned with north symbol clearly marked
Municipal address, names of adjacent streets, project name, applicants name, name of firm
preparing plans
Drawing title and number, preparation date, dates of any revisions
5) In the event that the application requires Site Plan Review Committee approval, the applicant must receive
support from the Site Plan Review Committee, for the layout of the site prior to making an application to
the Committee of Adjustment. This support does not bind the City of Waterloo in supporting the
Committee of Adjustment Application.
For Your Information
A public notice sign, which will be provided to you, is required to be posted in a prominent location
on the property for10 days prior to the hearing
Supporting materials, such as: a letter of explanation, letters in support, etc. should be submitted as far
in advance of the Hearing as possible
It is recommended that you discuss the proposal with adjacent neighbours in order to address or
alleviate concerns that may affect the disposition of your application
Staff comments will be available for pickup by any interested party the morning of the meeting date
The application fee is non-refundable
Applicants Signature and Acknowledgment
I/we acknowledge submission of this application does not necessarily mean that it is a “complete” application.
The City of Waterloo may return the application to the applicant for failure to complete any part of the
application form, failure to provide the required supporting documentation or failure to pay the application
fee. I/we acknowledge that it is my/our responsibility to provide a complete and accurate application and that
the City of Waterloo staff are not permitted to complete the application on my/our behalf. I/we agree to
received support from the Site Plan Review Committee and agree that a hearing before the Committee of
Adjustment may be deferred pending review by the Site Plan Review Committee. I/we consent and authorize
representatives of the City of Waterloo and those persons identfied under the Planning act R.S.O., 1990 c.
P13, to enter upon the land subject to this application for the purpose of conducting any site inspections and
take pictures as may be necessary for the evaluation of this application.
Signature of the Applicant/Authorized Agent
int Name
Owner Authorization
* It is required that the persons signing this authorization on behalf of companies/corporations have the
cessary authority to bind those corporation(s).
I/we, owner of the lands that are subject to this application,
(name of property owners)
hereby authorize to act on my/our behalf in
(name of agent/person authorized to sign application form)
regard to this application.
Signature of Owner(s): Date:
(to be completed in person in the presence of a commissioner of oaths, etc.)
f the Town/City of
in the County/Regional Municipality of , solemnly declare
that all of the statements contained in this application, including all the supporting documentation provided in
support of 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
SWORN before me at the Town/City of in the County/Regional
Municipality of , this day of , 20
Signature of Applicant/Authorized Agent A Commissioner, etc.
One (1) copy required with original signature
To the extent that the foregoing information constitutes personal information as defined in the Municipal
Freedom of Information and Protection of Privacy Act, R.S.O., 1990 c.M. 56 as amended, the information is subject
to the provisions of that Act and will be used for the purposes indicated or implied by this form. Collection of
personal information should be directed to the Commissioner of Integrated Planning and Public Works,
Waterloo City Centre, 100 Regina Street South, P.O. Box 337, Station Waterloo, Waterloo, ON N2J 4A8.
Telephone 519-886-1550.
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