Fillable Ceqa Document Declaration Form printable pdf download

County of Santa Clara

Office of the County Clerk-Recorder

Business Division

County Government Center

70 West Hedding Street, E. Wing, 1

Floor

NOTE:

San Jose, California 95110 (408) 299-5688

Before printing, be sure to Update the Total Value by

clicking in the RED BOX at the bottom of this form.

CEQA DOCUMENT DECLARATION

ENVIRONMENTAL FILING FEE RECEIPT

PLEASE COMPLETE THE FOLLOWING:

1. LEAD AGENCY: ________________________________________________________________________________________________________

2. PROJECT TITLE: _______________________________________________________________________________________________________

3. APPLICANT NAME: ____________________________________________________________ PHONE: ________________________________

4. APPLICANT ADDRESS: _________________________________________________________________________________________________

5. PROJECT APPLICANT IS A:

Local Public Agency

School District

Other Special District

State Agency

Private Entity

6. NOTICE TO BE POSTED FOR ________________ DAYS.

7. CLASSIFICATION OF ENVIRONMENTAL DOCUMENT

a. PROJECTS THAT ARE SUBJECT TO DFG FEES

0.00

1. ENVIRONMENTAL IMPACT REPORT (PUBLIC RESOURCES CODE §21152)

3,070.00

$_______________

0.00

2. NEGATIVE DECLARATION (PUBLIC RESOURCES CODE §21080(C)

$_______________

2,210.25

0.00

3. APPLICATION FEE WATER DIVERSION (STATE WATER RESOURCES CONTROL BOARD ONLY)

850.00

$_______________

0.00

4. PROJECTS SUBJECT TO CERTIFIED REGULATORY PROGRAMS

1,043.75

$_______________

0.00

5. COUNTY ADMINISTRATIVE FEE (REQUIRED FOR a-1 THROUGH a-4 ABOVE)

50.00

$_______________

Fish & Game Code §711.4(e)

b. PROJECTS THAT ARE EXEMPT FROM DFG FEES

0.00

1. NOTICE OF EXEMPTION ($50.00 COUNTY ADMINISTRATIVE FEE REQUIRED)

50.00

$_______________

2. A COMPLETED “CEQA FILING FEE NO EFFECT DETERMINATION FORM” FROM THE

DEPARTMENT OF FISH & GAME, DOCUMENTING THE DFG’S DETERMINATION THAT THE PROJECT

WILL HAVE NO EFFECT ON FISH, WILDLIFE AND HABITAT, OR AN OFFICIAL, DATED RECEIPT /

PROOF OF PAYMENT SHOWING PREVIOUS PAYMENT OF THE DFG FILING FEE FOR THE

SAME

PROJECT IS ATTACHED ($50.00 COUNTY ADMINISTRATIVE FEE REQUIRED)

DOCUMENT TYPE:

ENVIRONMENTAL IMPACT REPORT

NEGATIVE DECLARATION

0.00

50.00

$_______________

c. NOTICES THAT ARE NOT SUBJECT TO DFG FEES OR COUNTY ADMINISTRATIVE FEES

NOTICE OF PREPARATION

NOTICE OF INTENT

NO FEE

$________NO FEE

8. OTHER: __________________________________________________________________________ FEE (IF APPLICABLE): $_______________

0.00

9. TOTAL RECEIVED……………………………………………………………………………………........................................................ $_____________

NOTE: “SAME PROJECT” MEANS NO CHANGES. IF THE DOCUMENT SUBMITTED IS NOT THE SAME (OTHER THAN DATES), A “NO EFFECT

DETERMINATION” LETTER FROM THE DEPARTMENT OF FISH AND GAME FOR THE SUBSEQUENT FILING OR THE APPROPRIATE FEES ARE

REQUIRED.

THIS FORM MUST BE COMPLETED AND ATTACHED TO THE FRONT OF ALL CEQA DOCUMENTS LISTED ABOVE (INCLUDING COPIES)

SUBMITTED FOR FILING. WE WILL NEED AN ORIGINAL (WET SIGNATURE) AND THREE COPIES. (YOUR ORIGINAL WILL BE RETURNED TO

YOU AT THE TIME OF FILING.)

CHECKS FOR ALL FEES SHOULD BE MADE PAYABLE TO: SANTA CLARA COUNTY CLERK-RECORDER

PLEASE NOTE: FEES ARE ANNUALLY ADJUSTED (Fish & Game Code §711.4(b); PLEASE CHECK WITH THIS OFFICE AND THE DEPARTMENT

OF FISH AND GAME FOR THE LATEST FEE INFORMATION.

“ . . . NO PROJECT SHALL BE OPERATIVE, VESTED, OR FINAL, NOR SHALL LOCAL GOVERNMENT PERMITS FOR THE PROJECT BE VALID,

UNTIL THE FILING FEES REQUIRED PURSUANT TO THIS SECTION ARE PAID.”

Fish & Game Code §711.4(c)(3)

(Fees Effective 01-01-2016)

Ceqa Document Declaration Form

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