Fillable Formirac389 Permit Application (Prince Edward Island Regulatory & Appeals Commission)

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Formirac389 Permit Application (Prince Edward Island Regulatory & Appeals Commission)

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IRAC389(03/3)
Part 1 - General
1.1 Applicant's Name:
1.2 Applicant's Address:
1.3 Telephone: 1.4 Facsimile:
1.5 Person Making Application:
1.6 Engineer:
1.7 Full Address:
1.8 Telephone: 1.9 Facsimile:
1.10 Application To: .1
o
Construct .2
o
Alter .3
o
Extend
1.11 Service: .1
o
Water .2
o
Sewer .3
o
Both
Part 2 - Project Details
2.1 State below gen eral description of project, including size and length of pipes, number of
hydrants, etc., and proposed commencement and completion dates:
2.2 Number of Customers t o be Connected to the System(s):
2.3 Method of Tendering: .1
o
Public .2
o
Invited
2.4 If Invited Tendering, State Reason:
Clear Form
IRAC389(03/03)
Part 3 - Cost Estimate(s)
3.1 Estimate of Costs: Water % Sewer %
.1 Materials & Supplies ________ ______ ________ ______
.2 Labour ________ ______ ________ ______
.3 Other (Specify) ___________ ________ ______ ________ ______
.4 Engineering ________ ______ ________ ______
.5 Total 100% 100%
3.2 Engineers Fees Include:
.1
o
Design .2
o
Project Management
.3
o
Inspection .4
o
Other (Specify) __________________________
.5
o
Record Drawings
Part 4 - Cost Allocation
4.1 Allocation of Costs: Water % Sewer %
.1 Developer-Landowner(s) ________ ______ ________ ______
.2 Utility ________ ______ ________ ______
.3 Other (Specify) ___________ ________ ______ ________ ______
.4 Total 100% 100%
4.2 Where 'Other' in 4.1.3 includes contributions from any go vernment or indi vidual, attach a
statement or correspondence that signifies the contributor's financial commitment to
the project.
IRAC389(03/03)
Part 5 - Impact on Rates
5.1 Provide below or attach a benefit/ cost analysis for the project. The analysis must show
the overall annual cost of the project (e.g. interest on debt, depreciation, additional
operating and maintenance costs, etc.), the incremental re venue that will be deri ved
from new customers, and the net impact the project will ha ve on existing customer
rates.
Part 6 - Reason for Project
6.1 Provide below or attach a statement that indicates the reason for the project.
IRAC389(03/03)
Part 7 - Other
7.1 The following items MUST accompany this application OR be filed with the Commission
before a Permit will be issued:
.1 A copy of the Certificate of Appro val issued by the Minister of Environment,
Energy and Forestry pursuant to the Environmental Protection Act;
.2 A detailed cost estimate;
.3 One set of Plans; and
.4 In cases where ser vice is to be e xtended into or from another municipality,
a copy of that Municipality's/Utility's appro val of the extension.
7.2 Declaration
I hereby declare that the answers made herein and the information appended
hereto are true and correct to the best of my knowledge, information and belief.
Date: _____________________ ________________________
Signature of Applicant
Send Completed Form and Attachments to:
The Island Regulatory and Appeals Commission
Suite 501, 134 Kent Street
P.O. Box 577
Charlottetown, PEI
C1A 7L1
Additional information may be obtained by contacting
Commission Staff at 892-3501 or by Facsimile at 566-4076.
Information on this Form is collected pursuant to the Water & Sewerage Act and will be used by the Commission in the administration of
the said Act. For additional information, contact the Commission at 902-892-3501 or by email at info@irac.pe.ca.
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Formirac389 Permit Application (Prince Edward Island Regulatory & Appeals Commission)

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Completed 24 July 2021

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