Farm 911 program registration form

Name*
First Last
Address*
Street Address Address Line 2 City Postal Code
Phone*
Email*
Located on the*
Municipal Road Name*
Have you marked your requested access?
- Yes, the entrance is marked.
Closest 911 Address*
Street Address Address Line 2 City Postal Code
Across the road*
Requested Lot
Requested Concession
Requested Ward
Plan Number
Roll Number
Consent*
I agree to the following:
This application is approved on the understanding that the FARM 911 access is to assist in emergency situations only. An approved application does not imply that use of the property may proceed without additional permits or approvals as required by your municipality and further does not constitute an approval of legal "entrance" unless directed by the municipality. It is the responsibility of the landowner to ensure signage remains visible and is maintained. IF the sign is knocked down or damaged, please contact the City of Quinte West Municipal Office for replacement.
Consent*
I/We confirm that we have read and understand the below stipulations.
ACKNOWLEDGEMENT:

I/We, the undersigned owners of the property subject to the application, acknowledge that approval of a Farm 911 Project application:

1. Is to assist in emergency situations only;
2. Does not permit further use or development of the property without the appropriate approvals:
3. Does not constitute the approval of an entrance from a public highway, nor does it deem the access safe for use or that it meets and municipal entrance standards;
4. Does not guarantee that access is adequate for emergency vehicles, and where access is not adequate, emergency vehicles may not be able to enter the property;
5. Requires the landowner to maintain and keep the access in good repair and ensure the signage remains visible and is maintained. Should the signage be damaged, knocked down or removed, the landowner shall contact the Municipality for replacement/repair of the signage.
Signature*
Consent*

By signing above, I hereby unequivocally agree and acknowledge that the Corporation of the City of Quinte West is in no way responsible for any damages to persons or property arising out of the above work and hereby undertake to save harmless and indemnify the Corporation and its employees, agents, boards, officers, directors, etc. from all suits, claims, demands, actions, damages, etc., whether same shall e with or without merit and from all costs to which the City may be put in defending such action, claim or demand in any way arising out of, or alleged to arise out of any work, service, operation or thing constructed, installed, maintained or done or omitted to be done by the City relative to this permit.

The location of the Farm 911 access will be staked by the applicant and shown on an aerial image.
Farm 911 program registration
Total
$ 0.00 CAD

Credit Card

Cardholder Name

Card Details

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