SETBACK APPLICATION - Northumberland County

SETBACK APPLICATIONReturn to:Administration Offices555 Courthouse Road,Cobourg, ON. K9A 5J6Fax (905) 372-1696 Phone (905) 372-3329Owner(s)__________________________________________________________________________NameMailing Address___________________________________________________________________Number/Street Town/City Postal CodeTelephone Number: _______________________________________________________________Home Work CellIs there also an Entrance Permit Application □ yes (fee included with entrance) □ noI hereby make application to erect/alter a ____________________ Lot ____ Conc. ____,Twp/Town/Village of _______________on the ___________side of County Road # _____The closest part of this structure to the centerline of the existing road will be no less than 30metres (100 feet)TO BE SUBMITTED WITH THIS APPLICATION1. Attach a copy of legal survey and deed.2. Attach a sketch showing location of structure on property and measurements.3. Distance from the County Road Centreline to proposed structure is _______4. A deposit and fee as set in Fee Schedule paid by certified cheque made payable toTreasurer, Northumberland County. This deposit may be used by the County to correctany damage to the County road resulting from construction activity by the applicant and/or hisagents. The deposit is to be returned at completion of the project should no damage occur.I/we understand that in addition to this permit I/we MUST obtain a building permit from theMunicipality concerned, as well as Health Department clearances etc. This permit EXPIRESSIX MONTHS from date of approval.The municipality in which this structure will be erected has setback and other regulationsgoverning zoning and the construction of various types of buildings. The by-law or regulationwhich calls for the greatest set back distance applies. This application is approved on theunderstanding that all County/Municipal regulations/by-laws are complied with.____________________________Date of Application__________________________________Signature of ApplicantFOR OFFICE USE ONLYCould this structure interfere with existing or future drainage? If yes, explain__________________________________________________________________________________________________________________________________Inspector ______________________________ Date______________________County Approval ___________________________ Date of Approval ________________Deposit Received________________________ Deposit Returned________________Page 1 of 2

FEE SCHEDULECONDITION FEE DEPOSIT TOTALNew Dwelling $ 250.00 $ 750.00 $ 1,000.00Dwelling Addition $ 250.00 $ 750.00 $ 1,000.00Structure more than18.6 square metres$ 250.00 $ 750.00 $ 1,000.00(200 sq feet)Structure less than 18.6square metres (200 sq $ 250.00 $ 750.00 $ 1,000.00feet)With two site visits $ 150.00 $ 150.00With one site visit $ 100.00 $ 100.00With no site visit $ 50.00 $ 50.00The Road Authority will determine how may site visits are required based on special conditionsand structure offset to County Right of Way. The fee and deposit are to be paid at the time ofapplicationPage 2 of 2