Development Services www.cvrd.bc.ca | [email protected]
I / We hereby apply under Part 14 of the Local Government Act for a;
Development Permit
Development Variance Permit Rezoning
Official Community Plan Amendment Other
Civic Address PID
175 Ingram Street | Duncan, BC | V9L 1N8 Phone: 250.746.2620 | Toll Free: 1.800.665.3955 | Email: [email protected]
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Land Use & Development Application
Property Details
Existing OCP Designation
Development Permit Area(s) - where applicable
Development Details
Purpose of Application - Please provide a brief description of the proposed development
Office Use
Only Date Received File Type (DP (GM or Board), VAR, RS,OCP)
Receipt No.
Fees Paid: $
Please note: Incomplete applications will be returned to the applicant. No hand drawings will be accepted. Napkin plans will not suffice. Please no crayon, and remember your application is one of many that we receive, and will be processed in the order they are received. Do not staple or bind any plans or documents being submitted.
Existing Zoning
Existing Water Servicing Existing Sewer Servicing
Proposed OCP Designation Proposed Zoning
Proposed Water Servicing Proposed Sewer Servicing
175 Ingram Street | Duncan, BC | V9L 1N8 Phone: 250.746.2620 | Toll Free: 1.800.665.3955 | Email: [email protected]
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CVRD Requirements
When providing Application Forms to the applicant, Regional District staff shall indicate which of the following attachments are required for this application. Additional information may also be required at a later date.
Required Received Details
Basic Requirements Pre-Application Meeting
x Complete application form
x Payment of applicable fees
x Current State of Title (issued within last 30 days)
x Copy of all charges to State of Title (rights-of-ways, easements, cove- nants)
x Development rationale
Site Plan
*Notes:
• Survey by BC Land Surveyor may be required
• See sample site plan for reference
x Maximum 11" x 17" site plan (including north arrow and scale)
x Location of existing and proposed driveways, pathways and patios
x Location and dimensions of proposed buildings and setbacks to existing lot lines, rights-of-ways, easements and covenants Location of all water features, including streams, wetlands, ponds, ditches, ocean, lakes on or adjacent to property Location of all existing and proposed water lines, wells, septic fields, sanitary sewer and storm drains
Location, dimensions of all vehicle and bicycle parking, disability parking, vehicle stops & loading
Stormwater management infrastructure and impermeable surfaces Above ground services, equipment and exterior lighting details Existing natural grade and finished grades of site including contour lines (including buildings and retaining walls)
Other:
Elevation Drawings All four elevations (front, rear and two sides)
Height measurements (height survey may be required) Exterior finishes and materials
Cross sections Other:
Additional Information
*Notes:
• Supporting plans and reports to be prepared by Qualified Professional (P. Eng, BCLSA, QEP, etc.)
Archeological assessment Environmental assessment Erosion and sediment control plan Geotechnical report
Parcel & impervious site coverage plan Landscaping plan by a qualified professional Stormwater management plan
Traffic impact assessment Riparian area assessment report Other:
Provincial Requirements
Note: This is not an exhaustive list; other provincial regulations may apply175 Ingram Street | Duncan, BC | V9L 1N8 Phone: 250.746.2620 | Toll Free: 1.800.665.3955 | Email: [email protected]
Page 3 of 4 Riparian Areas
Protection Regulation
Please indicate whether any works will take place within:
yes 30 metres of the high water mark of any water features
yes
no
no a ravine or within 30 metres of the top of a ravine bank
“Water features” includes; 1) a watercourse, whether it usually contains water or not; 2) a pond, lake, river, creek, or brook; 3) a ditch, spring, or wetland that is connected by surface flow to 1 or 2 above.
Under the Riparian Areas Protection Regulation, a riparian area assessment report may be required before this application can be processed (see Riparian Areas Regulation Brochure).
Pursuant to the Local Government Act and the Species at Risk Act, please identify whether the subject property is:
yes no A. Located within 100 metre radius of all great blue heron nest trees.
Critical Habitat
Are there archaeological sites or resources on the subject property?
Archaeological Resources
yes no I don’t know
Common Provincial Contacts (subject to change without notice)
Archaeology Branch of British Columbia 1.250.953.3334
BC Land Title & Survey Authority (LTSA) 1.877.577.5872
Front Counter BC (for any provincial application) 1.877.855.3222
Island Health (Health Protection & Environmental Services) 1.250.737.2010 Ministry of Transportation and Infrastructure (Electoral Area G & H) 1.250.751.3246 Ministry of Transportation and Infrastructure (Electoral Area A, B, C, D, E, F & I) 1.250.952.4515
yes no B. Located within 60 metre radius of all eagle, hawk, osprey, owl or peregrine falcon nest trees, or other nest trees of sensitive, rare and endangered species.
yes no C. Located in close proximity to a sensitive ecosystem, and/or endangered species protection area.
For further information please contact the Archaeology Branch of BC.
Please complete the Site Disclosure Statement at the end of this application form. If the property has never been used for an activity outlined in Schedule 2, only Section I. and III. of the Site Disclosure Statement need to be completed. Alternatively, the Site Disclosure Statement may be completed online using the following link (note: right click the link and 'open link in a new tab'):
https://chefs.nrs.gov.bc.ca/app/form/submit?f=32a95812-f9db-4fd2-99eb-7e362b0253b1 Site
Contamination
175 Ingram Street | Duncan, BC | V9L 1N8 Phone: 250.746.2620 | Toll Free: 1.800.665.3955 | Email: [email protected]
The property described above is the subject of this application and is referred to herein as the ‘subject property’. This application is made with my full knowledge and consent. I declare that the information submitted in support of the application is true and correct in all respects. By completing this application form, the owner and/or applicant hereby is aware and authorizes site inspections to be conducted by Regional District staff and Advisory Planning Commission members as appointed by the Regional Board.
Agent Information
Name of Owner (print) Signature of Owner Date
Name of Owner (print) Signature of Owner Date
Name of Owner Phone Number
Address City
Email Postal Code
Owner Information
I, the owner, hereby give permission to ____________________________ to act as my/our agent in all matters relating to this application.
Signature of Owner Date
Signature of Owner Date
Page 4 of 4 Personal Information Declaration: This information is collected pursuant to Part 14 of the Local Government Act and CVRD Development Application Procedures and Fees Bylaw No. 3275. This information has been collected and may form part of the public record and may be included in a meeting agenda that is posted online when this matter is considered before the Board or a Committee of the Board. I hereby consent that all information, including personal information, contained in this document including all attachments maybe made available to the public. Note: For more information on disclosure, contact the CVRD FOI Coordinator at 250.746.2507 or 1.800.665.3955.
Owner and Agent Declaration
Signature of Agent Date
Name of Agent Company
Address Phone Number
Email Postal Code
Agent
Authorization
Contaminated Sites Regulation (Environmental Managment Act)
Schedule 2 - Specified Industrial of Commercial Uses
Note that this Schedule 2 excerpt has been provided for convenience only. Please confirm the applicable uses on Schedule 2 of the Contaminated Sites Regulation (note: right click the link and 'open link in a new tab'):
https://www.bclaws.gov.bc.ca/civix/document/id/complete/statreg/375_96_04#Schedule2
Contaminated Sites Regulation (Environmental Managment Act)
Schedule 2 - Specified Industrial of Commercial Uses
Contaminated Sites Regulation (Environmental Managment Act)
Schedule 2 - Specified Industrial of Commercial Uses
Contaminated Sites Regulation (Environmental Managment Act)
Schedule 2 - Specified Industrial of Commercial Uses
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SCHEDULE 1
SITE DISCLOSURE STATEMENT
A. Site Owner (s) or operator (s), as applicable (add extra pages, if necessary)
Last Name First Name (s)
Company (if applicable)
Owner/Operator Address
City Province/State
Country Postal/Zip Code
Telephone ###-###-#### Email
B. Person Completing Site Disclosure Statement (Leave blank if same as above):
Agent authorized to complete form on behalf of the owner or operator
Last Name First Name
Company (if applicable)
C. Person to Contact Regarding the Site Disclosure Statement:
Last Name First Name (s)
Company (if applicable)
Mailing Address
City Province/State
Country Postal/Zip Code
Telephone ###- ###-#### Email
I. CONTACT INFORMATION
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Coordinates (using the North American Datum 1983 convention) for the centre of the site:
Attach a map of appropriate scale showing the location and boundaries of the site.
For Legally Titled, Registered Property
Site Address (or nearest street name/intersection if no address assigned)
City Postal Code
PID numbers and associated legal descriptions.
PID Land Description
For Untitled Crown Land
PIN numbers and associated Land Description (if applicable).
PIN Land Description
(and, if available) Crown Land File Numbers
Longitude Degrees Minutes Seconds
Latitude Degrees Minutes Seconds
II. SITE INFORMATION
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Has the site been used for any industrial or commercial purposes or activities described in SCHEDULE 2 of the Contaminated Sites Regulation?
YES NO
If you answered YES to the question above, please indicate below, in the format of the example provided, which of the industrial or commercial purposes or activities have occurred or are occurring on this site.
EXAMPLE
1. Provide a brief summary of the planned activity and proposed land use at the site.
2. Indicate the information used to complete this site disclosure statement including a list of record searches completed.
3. List any past or present government orders, permits, approvals, certificates or notifications pertaining to the environmental condition of the site. (Attach extra pages, if necessary):
Schedule 2 Reference Description
E1 appliance, equipment or engine maintenance, repair, reconditioning, cleaning or salvage F10 solvent manufacturing, bulk storage, shipping or handling
Schedule 2 Reference Description
IV. ADDITIONAL INFORMATION
III. INDUSTRIAL OR COMMERCIAL PURPOSES OR ACTIVITIES
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1. Exemptions (See the Contaminated Sites Regulation, Division 3 of Part 2):
Does the application qualify for an exemption from submitting a site disclosure statement?
Yes If yes, indicate which exemption applies No
2. Where a municipal approval is not required, please indicate the reason for submission directly to the registrar:
Under Order Foreclosure CCAA Proceedings BIA Proceedings Decommissioning Ceasing operations
By signing below, I confirm that the information in this form is complete and accurate to the best of my knowledge:
Signature Date Signed (YYYY-MM-DD)
FOR OFFICIAL USE – APPROVING AUTHORITY (e.g. LOCAL GOVERNMENT)
Reason for submission (Please check one or more of the following) Building permit
Subdivision Zoning
Development permit
Approving Authority Contact Information
Name Agency
Address
Telephone ###- ###-#### E-mail
Date Received (YYYY-MM-DD) Date Submitted to registrar (YYYY-MM-DD)
