File No: Note on fees: The application fees were adopted and approved under By-law No by the Council of the Township of Southgate.

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1 Cuesta 03:29:01 pm /47 The Corporation of The Township of Southgate Consent application form Instructions: Please check all appllcable boxes and answer all applicable questions Several of the questions are part of the minimum mandatory requirements as prescribed In Schedule 1 to Ontario Regulation 41/95, Planning Act, and must be completed Fallure to provide adequate, correct Information may result Jn your application being refused All measurements MUST be In metric units (Imperial Units will not be accepted) Addltlonal Information may be attached If necessary Incomplete appflcatlons wlll be returned The Township reserves the right to ask for more Information or clarificatlon pertaining to this appllcatlon at a later time Applications are not accepted without the required fees For office use onlv File No: B 7-f ('p Date received: Date accepted Accepted by: Roll # 42 07, ;~_,~, 1 Conservation Authority Fee Required : Other Information: It Is strongly advised that any potentlal applicant pre-consult with the Planning Department prior to submitting any plannlng application This could save you money and avoid delays In processing Staff are avallable to provide some assistance In completing this appllcatlon and will help ensure the application Is filled out completely The Approval Authority is the Township of Southgate Committee of Adjustment Re uired Fees: - A llcatron Fees Public Notice SI n Fee Parkland Dedication Fee Deed Stam in Conservation Authority Fee arr new residential lots due before finalization of a roved consent SVCA $ (per each net lot created) GRCA - Call dlrectl for details I I 0 Note on fees: The application fees were adopted and approved under By-law No by the Council of the Township of Southgate All required application fees shall be paid In cash or by cheque made payable to the Township of Southgate at the time of submission of the appllcatlon, Please review the required Conservation Authority fees prior to submitting your appllcatlon Saugeen Valley Conservation Authority requires their fee to be submitted to the Township of Southgate along with thls application In the event that all fees are not paid In full at the time of submission, the appllcatlon shall be deemed Incomplete [; \Plannlnq\AoollcaUons and fonns\consent Aool/Cj'ltfon revised 2014pdf

2 - ~ ~ "', ; ~, -: ~ - - "" Cuesta ' : \ : - - ' :~ ' :"'" l!art~rwo,: t: ' l, "1 -: ;,,, :' ~ ~- :,, -c ~ ---=,, _ ~, ~ ' ;; :--, ~ ': ~; _ ' -~ l\jt : subjec Lancb (~gal pescrlpt1bnl, ~- ':;: _!_ " o ' I V ~ 0 1 ' ',,~ '_" NorEf on fh/s'forrrf~subjecr LAND" 'mt?in!f'tm':parce~ to 'be severeti ~t11e:parcel ta;~e : ~ : ~ - "' '": - ' :retained,l " 't ' i; - ~ :- 1 ForriierMunfclpi!lltY: 'Egremont' \ : <~ :,,,, ' ~:- M:! : 'Road Nafue1 Gray R'oad,:14 :,,_ ajvrc):cj& ress;c~i'i), t fo', Q} to <5 b G ~ff~ iz-c:i/4{ f~ot No, ~L'2a ~ Plani9i~~e~s 101r~ ;lf' :~ ~ -:: _ - ~ -;-, - F: ~- : Part_' _- ri ererence 1 PlamrJo _ - ~ "' --= "--- _ ;_"'- ;;:,; """ ~ "" ' - "-'---= - - ;~ -' ~'"" ' : ',, :, - ~ " ~ ~ '~ ~ - ' : - : ~, t"i" ~ ""' - ~ : : ~ er 1s the 1lsubject' l~nd 11;r~~~~v-su!)Ject to ~~~~(th'e : f&'jlpvtfrigf " ~~ - "rt,' s : -~ :,; ~reas~ment ~1:;i;fi~trlctlye ~~~e~auts '" - UJ ~fgh~ orw~v -;? _ - ~ ~~~~~~~~~~~~~ _ ;_~~;;;~~~~~~~-'-~~~;;~~;;-=~ ;_ ~_-?- ;~ ~ Describe ' Utility BolioVinlid by BellCan;idi_, ~, - -: " / :: -: - / - - "" : ~ - :i, ' NOT~: ~,; e:l;tjhg! eas~m~ritia~d,rl~~t~~f wa~s ~ustb~:sho1'4n ~~n ' the ~l(;t<=h :;~ ~ J -::~ ;~ ~- : -: - : -;: : : : ',~ -! " ', ~ I "'"" I, ; < "\, ~!' " : : ~ : ~-~ -: ; '"-~ ~ r 1 ;, ~ ~,! ~ ":~ ";: : ~, \::~ '-, : ~ ", i- ' :" ~ : :_:: - = \, ;- :,, : 'Ii - :" - : --, :'-i" --;

3 ,15193:129953, c, ', 1 Cuesta a: 'Io ' ' " v) Correction:oflltle, ""'" :, ~ ~ --: ~ t - '"':'" 6 -,_ 4 _ I : ;' : - -<' - :: -, vi} Othe~ '[J " ; 10 ; PrQPOs~cJ, use,~ f;f~nd to~be:se'ief~d, 'E>iistfng:bullaffigs Nol;e p! "; ' - - ~ Propcise~ buti~lngs, :one ~(Geaeiai:slo;,,1, _,,, ~ ' "' - ' : ' J' ' - '-:"' -~ 11, Propos ~cf us~ of:laf\4 ~o b ~ retaln~d ', J" ;, <': Existing bulldtngs BilllJ ~n,!i Fann owelllng, - \ " : ~ propos~d ib'ulldlngs_n_o;n'-e '- _::,_~_; : ;; _ ; '------' :; ' ~: - <M, :- ' - Q rnon ~rarm restdent1a1 ~- ' ~SsurollJs'fa rm dwelllha ; J, llsj'a'arlcultural:, - ~ ' ~IJ ;A"grlclllhlral relrhedt '; - I : l:l'robbv,-farm : ~ t:j Gommerclal/Jndusti1af, f, ~ :,' ' ~, ~ ~e:otner-{soedm : ~ -, ~ ~ \I,,, s ( ~ : _ ', -:, f"~ ~: - :,, J, ' :J~; - -:, ~ ' ": ' - ~-,~ ',, t" ) ~ :

4 151 ::! Cuesta 03:29:46 pm /47 r a g e 1_4 12 Original lot being added to (lot addition only): PL Loi 29 Con 4 Egremont Existing bulldlngs/structu res: v""'acan ==t Use: Vacant Access: Grey Road 14 Servicing: Private water and septic 13 Road Access: Severed Parcel Retained Parcel Provincial Hiohwav(Provlde Road Number) Cl Cl Countv Road (Provide Road Number) Q!I llil Southgate Road {Provide Road Number) 0 0 Non-maintained/seasonally maintained Cl 0 Munlcloal road allowance If access Is from a non-maintained or seasonally maintained road allowance has an agreement been reached with the munlclpallty regarding upgrading of the road? CJ YES CJ NO Private Rloht-of-Wav D 0 14 Servicing: a) What type of water supply Is proposed? Severed Parcel Retained Parcel Municipally owned/operated water supply Cl Cl Lake/River Cl Cl Private well - Individual!XI IXI Private well - Communal Cl Cl If proposed water supply Is by private well, are the surrounding water well records attached? Cl YES Cl NO b) What type of sewage disposal Is proposed? Se_vered Parcel Retained Parcel Municlpally owned/operated sanitary sewers Cl Cl Individual Private Septic (29 ~ Communal Private Septic Cl Cl Privy Cl Cl Other (Specify) Cl Cl c) other services (check If any of these services are avallable to the "subject landn) Electrlclty ll!i School Bus Cl Telephone l!i Garbage Collection ll!i 15 Agrlcultural property history If this property Is Agricultural In nature or located within 450m (1476 feet) of a barn or llvestock facility, you must complete Schedule "A~ found at the end of this application (Exception for minor lat line adjustment),

5 15193") Cuesta 03:29: 59 pm /47 Part Four 16 Appllcable leglslatlon and policies a) Is this applicatlon consistent with policy statements Issued under subsection 3 {1) of Plannlng Act? IXI Yes 0 No b) Is the subject land within an area of land designated under any provlnclal plan or plans? 0 Yes Oll No I) lfthe answer to section b) Is yes, does this appllcatlon conform to, or not conflict with, the applicable provincial plan or plans 0 Yes 0 No c) Please Indicate the existing Southgate Offlclal Plan deslgnatlon(s) of the subject land: 0 Agriculture 0 Space Extensive Industrial/Commercial C3 Rural 0 Mineral Aggregate Extraction 0 Village Community Oll Hazard Lands 0 Inland Lakes 0 Wetlands 0 Major Open Space 0 Neighbourhood Area 0 Arterial Commercial a Downtown Commercial Industrial a Special Polley Area a Publlc Space d) Please Indicate whether any of the fallowing Constraint Areas In Southgate Official Plan apply to the subject land: O Primary Aggregate Resource Areas O ANSI O Existing/known abandoned Land Fiii Sites D Deer wintering yard e) Does the application conform to the Southgate Official Plan? a Yes 1XJ No There ere associated County and Twp policy amendment appllcauons currently In process f) Has any land been previously severed from the original parcel of land? IXI Yes a No If yes, how many severances? -'2=----- Indicate year, file #'s, if known_n_ia g) Has the parcel Intended to be severed ever been, or Is It now, the subject of an application for a plan of subdivision under the Planning Act? a Yes 0 No QSI Unknown h) Is the application being submitted In conjunction with a proposed County Official Plan Amendment? 11!:1 Yes a No I) Is the applicatlon being submitted In conjunction with a proposed Southgate Official Plan Amendment?!XI Yes a No j) Has an application for a zoning by-law amendment, or a minor variance, been submitted to/or approved by the Township of Southgate? llil Yes a No I) If yes, please provide some additional Information: Submllled with this appllcauon File # Submitted Approved Fiie # Submitted Approved

6 15193; Cuesta 03:30:15 pm I'~ g e 18 Part Five 18 Owner's Consent {Freedom of Information): In accordance with the provision of the Planning Act, It Is the policy of the Munlclpallty to provide public access to all development applications and supporting documentation In submitting this development application and supporting documentation I(we), Vernon McQueen and _j vi V'""\ e, \1\) O 9- o-_ name of owner(s) ::;> hereby acknowledge the above-noted and provide my/(our) consent, In accordance with the provisions of the Municipal Freedom of Information and Protection of Privacy Act, that the Information on this appllcatlon and any supporting documentation provided by myself, my agents, consultants and solicitors, as well as commenting letters of reports Issued by the municipality and other review agencies wlll be part of the public: record and wlll also be available to the general public ~ CJtvc~ ~owner 19 Owner authorization for agent I/we VemanMcQueen, ~\A'C '\C Wo~ authorize Cuesta Planning Consultants Inc to act as our agent(s)for the purpose of this appllcatlon ~~/?1 -(:ffm: 9Jft!:'«nr ~c:~ cdz?- -??n~"- ~ Sig of Owner Signature of Witness Dated at the T_o_wn_s_h_iP of Southgate this li,/ day of ~=---==-µj= "' # 20 Owners authorization for access I/we Vemon McQueen, ~ Hereby do permit Township staff and Its representatives to enter upon my/our lands during regular business hours for the purpose of performing Inspections of the subject property as It relates to evaluation of this appllcatlon V9zca1n, 1n c; ~ ~wner

7 1s1n/29953 Cuesta 03:30:28 pm /47 Pu ge Affidavit or sworn declaration Note: This Affidavit must be signed In the presence of a Commissioner for Taking Oaths 11 (We> June \"-Jo~ ""'"- Ver ooo µ l G1Jee() Name ner(s) or Authorized Agent of thetw~ of -5>y~ lnthe ~~of 0r~ ty/townshlp/mun~ ounzy/reglon Solemnly declare that all statements contained In this application and all the Information provided Is true, and I/we make this solemn declaration consclentlously bellevlng It to be true and knowing that It Is of the same force and effect as ff made under oath and by virtue of the Canada Evidence Act Declared before me at the: Tw~ of SD~oti In the cty/townshfp/munlcfpility This-3_ day of /+u_duq 1-,2011P Cwn-htor 6rUi cbunzy/reglon q/ ~ c;ri~~ Signature of Owner a4zc~ ~eofowner ~\A 9 Date I 2_o\ c_ Return this completed form and payment to: Attention: Committee of Adjustment Township of Southgate Grey Road 9, RR 1 Dundalk Ontario NOC 180