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City of Clarence-Rockland Application for Consent
Page 1 of 10 Version: 2021
CORPORATION
de la Cité de / of the City of
CLARENCE-ROCKLAND
APPLICATION FOR: CONSENT
Personal information contained on this form is collected pursuant to the Municipal
Freedom of Information and Protection of Individual Privacy Act
and will be used for
the purpose of responding to your request. Questions about this collection should
be directed in writing to the Freedom of Information and Privacy Coordinator of the
City of Clarence-Rockland.
Please refer to A Guide to Consents for more information regarding application
requirements, fees, and the review process. A pre-consultation meeting with a
municipal planner is required prior to submitting an application. Reference should
be made to the Planning Act, the Official Plan and Zoning By-Law of the City of
Clarence-Rockland as well as the Official Plan of the United Counties of Prescott-
Russell. In case of doubt or difficulty, enquiries should be directed to the:
Infrastructure & Planning Department
City of Clarence-Rockland
1560 Laurier Street
Rockland, Ontario
K4K 1P7
Phone: (613) 446-6022
Fax: (613) 446-1497
www.clarence-rockland.com
For office use only
Date received:
Date deemed complete:
File number:
City of Clarence-Rockland Application for Consent
Page 2 of 10 Version: 2021
GENERAL INFORMATION
1. Pre-consultation with a municipal planner is required before submitting an
application. Additional consultations with various provincial ministries may be
recommended. You should familiarize yourself with the Provincial Policy Statement,
the applicable Official Plans and the City of Clarence-Rockland Zoning By-law.
2. Where development is proposed in areas where water or septic services are to be
provided through private on-site services, it is strongly recommended that you
contact South Nation Conservation at 38 Victoria Street, Finch, ON, K0C 1K0,
www.nation.on.ca, at 613-984-2948 or toll free at 1-877-984-2948, prior to
submitting your application in order to ensure that your proposal is consistent with
provincial standards respecting water supply and septic system installation. These
standards may affect the size and configuration of the proposed severed and
retained lots.
3. The original application is to be completed and submitted to the Infrastructure &
Planning Department of the Corporation of the City of Clarence-Rockland in paper
and digital (PDF) format and must be signed by all the applicant(s) and owner(s) of
the affected lands. The application must be accompanied by:
i) Fees for the amount indicated on the attached Schedule B. The fees for the
application represent a portion of the anticipated costs for the processing of
the application;
i) A Cover Letter or Planning Rationale
describing the application and
outlining reasons for its support and justification;
ii) A sketch indicating the proposed dimensions of the
lots as well as the location
of any buildings or structures, well and septic system (see Section 9);
iii) One copy of any additional supporting information (see Section 10);
iv) A recent copy of the Deed of Land or Parcel Register
indicating the name
of the current property owner as well as a complete legal description of the
property;
4. If, in the opinion of the Manager of Development, the application is not complete (as
described in the Planning Act of Ontario, R.S.O. 1990, as amended)
, the required
circulation of the application and any necessary hearing will be delayed until a
complete application is submitted.
5. For more information regarding the review process and the timeline for approval
once a complete application has been su
bmitted, please refer to the City’s process
guide (A Guide to Consents).
City of Clarence-Rockland Application for Consent
Page 3 of 10 Version: 2021
Section 1 – Contact Information
Registered Owner (name): ___________________________________________
Contact person (if owner is a corporation): _____________________________________
Mailing Address: __________________________________________________________
Home: ________________
Work: _________________
Cell: _________________
Email:
Applicant (name): __________________________________________________
Mailing Address: __________________________________________________________
Home: ________________
Work: _________________
Cell: _________________
Email:
Agent (name): _____________________________________________________
Mailing Address: __________________________________________________________
Home: ________________
Work: _________________
Cell: _________________
Email:
All persons having a mortgage charge or encumbrance on the property:
Name: __________________________________________________________________
Mailing Address: __________________________________________________________
______________________
Email: ___________________________________
If more than one, include on a separate page.
Name of the person to whom the land is intended to be conveyed or leased:
Correspondence:
I/we prefer to receive correspondence in:
French
English
I/we prefer to receive correspondence via:
Letter mail
Email
Send correspondence to:
Owner
Applicant
Agent
Did you have a pre-consultation meeting
with the Development Review Team or
with a municipal planner?
Development
Review Team
Planner None
Name of planner: ___________________________________
Date: _______________
Section 2 – Application Type
What is the purpose of the application for consent?
Creation of a new lot
Residence surplus to a farming operation
Addition to a lot
Easement/Right-of-way
A charge
A lease
A correction of title
Other (please describe below)
Details:
City of Clarence-Rockland Application for Consent
Page 4 of 10 Version: 2021
Section 3 – Description of the Subject Property
Please include all applicable information. This section covers the entire subject property.
Civic Address: ___________________________________________________________
Lot: _______
Concession: _________
Geographic Township: Clarence
Reference Plan Number: __________________
Part(s): ______________________
Subdivision Plan Number: _________________
Lot/Block: ____________________
Roll Number: ________________________
PIN(s): _____________________________
Lot area:
m
2
ft
2
Lot depth:
m
ft
Width/frontage:
m
ft
If this application is for an addition to a lot, please indicate the parcel which will be enlarged:
Civic Address: ____________________________________________________________
Lot: _______
Concession:__________
Geographic Township: Clarence
Reference Plan Number: ____________________
Part(s): _______________________
Subdivision Plan Number: ___________________
Lot/Block: _____________________
Roll Number: ________________________
PIN(s): _____________________________
Name of owner: ___________________________________________________________
Is the property subject to any easements or
restrictive covenants?
Yes No
Instrument Number: _________________________
Description/Effect:
________________________________________________________________________
Section 4 – Description of severance requested
Parcel dimensions
Frontage (m)
Depth (m)
Area (m
2
or ha)
Severed parcel (A)
Retained parcel (B)
Enlarged parcel (C)
* Please note, there is a maximum of one severed parcel (A) and one retained parcel (B) per
consent application. Please use metric units only.
Existing and proposed land uses, buildings and structures
Existing
Proposed
Severed parcel (A)
Land Use:
Buildings:
Retained parcel (B)
Land Use:
Buildings:
Enlarged parcel (C)
Land Use:
Buildings:
Adjacent land uses:
North:
South:
East:
West:
City of Clarence-Rockland Application for Consent
Page 5 of 10 Version: 2021
Section 5 – Access and Services
Type of access
Severed Parcel (A)
Retained Parcel (B)
Enlarged Parcel (C)
Existing / Proposed
Existing / Proposed
Existing / Proposed
County Road
Municipal Road
Private Road
Right-of-way
Easement
Water Access
Other
For water or other access, please describe:
Is there an existing entrance or culvert on the property? If yes, how many and on which road?
Type of water supply
Severed Parcel (A)
Retained Parcel (B)
Enlarged Parcel (C)
Existing / Proposed
Existing / Proposed
Existing / Proposed
Municipal water
Private individual well
Private communal well
Lake or other water body
Not required
Other
For other water source, please describe:
Type of sanitary sewage disposal
Severed Parcel (A)
Retained Parcel (B)
Enlarged Parcel (C)
Existing / Proposed
Existing / Proposed
Existing / Proposed
Municipal sanitary sewers
Private individual septic
Private communal septic
Pit privy
Not required
Other
For other sanitary sewage disposal, please describe:
Type of stormwater management
Severed Parcel (A)
Retained Parcel (B)
Enlarged Parcel (C)
Existing / Proposed
Existing / Proposed
Existing / Proposed
Municipal storm sewers
Roadside ditch or swale
Other
Date of installation for proposed services:
City of Clarence-Rockland Application for Consent
Page 6 of 10 Version: 2021
Section 6 – Related Applications
Past Applications
Has the subject land been the subject of an
application for a plan of subdivision or a consent
under the Planning Act?
Yes No Unknown
If yes:
File Number:
Status:
Year:
Has any land been severed from the parcel originally acquired by the
current owner of the subject property?
Yes No
If yes:
Date of transfer:
Name of transferee:
Land use:
Have any new lots been created from the original lot as it existed on June 22, 1999?
Yes
No
If yes, how many? ______________________
Concurrent Applications
Is the owner, applicant, or agent applying for additional consents on
this or any other property simultaneously with this application?
Yes No
Is this application for consent related directly to an Official Plan or
Zoning By-law Amendment or a Minor Variance application currently
under review by an approval authority?
Yes No
If yes:
File Number:
Status:
Is this a resubmission of a lapsed application?
Yes
No
If yes:
File Number of previous application:
Section 7 – Planning Designation
Land Use
What is the current land use designation in the:
- Official Plan of the United Counties of Prescott and Russell?
- Official Plan of the Urban Area of the City of Clarence-Rockland or Bourget Official Plan?
What is the zoning category of the subject property?
Environmental Constraints
Is there a Provincially significant wetland located on the parcel to
be retained or severed?
Yes
No
Is any portion of the parcel to be retained or severed within a
floodplain?
Yes
No
Is any portion of the parcel to be severed within 120 metres of a
designated natural heritage feature as identified in the Official Plan
of the United Counties of Prescott and Russell?
Yes
No
If yes: Please list and describe the natural feature(s):
City of Clarence-Rockland Application for Consent
Page 7 of 10 Version: 2021
Section 8 – Additional Information
Application Details
Is the proposed consent consistent with the Provincial Policy
Statement, 2014 and with all applicable Official Plans?
Yes
No
Does the proposal for the subject lands conform to the existing
zoning?
Yes
No
If not:
Has an application been made to amend the zoning by-law?
Yes
No
If yes:
File Number:
Has an application been made for a minor variance?
Yes
No
If yes:
File Number:
Will the retained or severed parcel be used for non-residential
development (for example, industrial or commercial uses) that will
generate more than 4,500 litres of sewage waste per day?
Yes
No
History of the Subject Property
Has there ever been an industrial use on the site?
Yes
No
If yes:
Nature/type of industrial use:
Has there ever been a commercial use on the site?
Yes
No
If yes:
Nature/type of commercial use:
Has there ever been petroleum or other fuel storage on the site, or
has the site been used for a gas station at any time?
Yes
No
If yes:
Use and type of fuel:
Is there any reason to believe that the site may have been
contaminated by former use(s) on the site or adjacent site(s)?
Yes
No
Neighbouring Land Uses
Is there an agricultural operation (including an abattoir, livestock
or stockyard) within 500 metres of the subject parcel?
Yes
No
Is there a building used to house livestock located within 500
metres of the subject parcel?
Yes
No
If yes:
Type of livestock:
Number of animals:
Is there a landfill site within 500 metres of the subject parcel?
Yes
No
If yes:
Is the landfill operational?
Yes
No
If no:
Date of closure:
Is there a sewage treatment plant or waste stabilization plant
within 500 metres?
Yes
No
Sources of Information
What did you do and/or what information did you use to answer all of the questions in
Sections 6, 7, and 8?
Consultation with:
Municipality
Previous Owner
or Neighbours
Registry Office
Other
Please explain:
City of Clarence-Rockland Application for Consent
Page 8 of 10 Version: 2021
Section 9 - Sketch
A complete application form must be accompanied by a sketch identifying the following
items:
1. The boundaries and dimensions of the subject property, including: the parcel to be
severed (A), the parcel to be retained (B), and the parcel to be enlarged, if
applicable (C).
2. The boundaries and dimensions of any land abutting the subject land that is owned
by the owner of the subject land.
3. The approximate distance between the subject land and the nearest municipal lot
line or landmark such as a bridge or railway crossing.
4. The location of all land previously severed from the parcel originally acquired by the
current owner of the subject land.
5. The approximate location of all natural and artificial features (for example, buildings,
driveways, railways, roads, watercourses, drainage ditches, banks of rivers or
streams, wetlands, wooded areas, wells and septic systems) that are located on the
subject land and on land that is adjacent to it, and are relevant to the application.
6. The current uses of land that is adjacent to the subject land (for example,
residential, agricultural or commercial).
7. The location, width and name of any roads within or abutting the subject land,
indicating whether it is an unopened road allowance, a public travelled road, a
private road or a right of way.
8. If access to the subject land is by water only, the location of the parking and boat
docking facilities to be used.
9. The location and nature of any easement affecting the subject land.
Section 10 - List of attached documents
Please list the titles of any supporting documents (e.g. Environmental Impact Study,
Hydrogeological Report, Traffic Study, Stormwater Management Report, etc.):
City of Clarence-Rockland Application for Consent
Page 9 of 10 Version: 2021
Section 11 – Owner’s Authorization
To be completed if the owner is not the applicant or has assigned an Agent to help manage the
application process.
I (we)
Name of Owner(s)
of
Village/Town
in the
County/Region
do hereby authorize
Name of Applicant or Agent
to act as my agent in this Application for Consent.
________________________________
Signature of Owner
________________________________
Signature of Owner
Date:
Section 12 - Affidavit
This must be signed in the presence of a Commissioner.
I (we)
Name of Owner(s) / Applicant(s)
of
Village/Town
in the
County/Region
solemnly declare that all the statements contained in this application are true, and I (we)
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.
DECLARED before me at
Village/Town
in the
County/Region
This day of ,
Day
Month
Year
________________________________
Signature of Owner
________________________________
Signature of Owner
________________________________
Signature of a Commissioner
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City of Clarence-Rockland Application for Consent
Page 10 of 10 Version: 2021
SCHEDULE A
Applicant’s Checklist
Please note that your application may not be deemed complete if any of the following items are not
included with the completed application form. The Infrastructure and Planning Department cannot
begin processing your application until it has been deemed complete.
A Cover Letter or Planning Rationale
A sketch, as described in Section 9
3 cheques for the amounts and to the agencies set out in Schedule B below
All supporting documents listed in Section 10
A recent copy of the Deed of Land or Parcel Register
SCHEDULE B
Consent Application Fees
There are three application fees for a consent application, each to be paid by separate cheque, made
out to the following agencies for the amounts specified:
1. City of Clarence-Rockland Application Fee:
$1,298.00 – Creation of a new lot
$920.00 – Addition to a lot, correction of title, residence surplus to a farming
operation, easement or right-of-way, charge or lease, etc.
2. South Nation Conservation Application Fee:
$480.00
3. United Counties of Prescott and Russell
$420.00
Please note that additional fees may be required to be paid following the conditional
approval of the application in order to clear the conditions applied.
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Completed 14 March 2022

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