____________________
(FOR LAFCO USE ONLY)
SAN BERNARDINO LAFCO
APPLICATION FOR
EXTENSION OF SERVICE BY CONTRACT
(A certified copy of the City Council/District Board of Directors resolution or a letter from the City Manager/General Manager requesting approval for an out-of-agency service agreement must be submitted together with this application form.)
AGENCY TO EXTEND SERVICE:
AGENCY NAME: _________________________________________ CONTACT PERSON: _________________________________________ ADDRESS: _________________________________________ _________________________________________
PHONE: _________________________________________
EMAIL: _________________________________________
CONTRACTING PARTY:
NAME OF
PROPERTY OWNER: _________________________________________ CONTACT PERSON: _________________________________________ MAILING ADDRESS: _________________________________________ _________________________________________
PHONE: _________________________________________
EMAIL: _________________________________________
ADDRESS OF PROPERTY
PROPOSED FOR CONTRACT: _________________________________________ _________________________________________
CONTRACT NUMBER/IDENTIFICATION: _________________________________________ PARCEL NUMBER(S): _________________________________________ ACREAGE: _________________________________________
Extension of Service by Contract ____________________
Application Form (FOR LAFCO USE ONLY)
The following questions are designed to obtain information related to the proposed agreement/contract to allow the Commission and staff to adequately assess the proposed service extension. You may include any additional information which you believe is pertinent.
Please use additional sheets where necessary.
1. (a) List the type or types of service(s) to be provided by this agreement/contract. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ (b) Are any of the services identified above "new" services to be offered by the agency? YES NO. If yes, please provide explanation on how the agency is able to provide the service.
________________________________________________________________ ________________________________________________________________ ________________________________________________________________
2. Is the property to be served within the agency's sphere of influence?
YES NO
3. Please provide a description of the service agreement/contract. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
4. (a) Is annexation of the territory by your agency anticipated at some point in the future?
YES NO. If yes, please provide a projected timeframe when it anticipates filing an application for annexation of territory that would include the area to be served. If no, please provide an explanation as to why a jurisdictional change is not possible at this time.
________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Extension of Service by Contract ____________________
Application Form (FOR LAFCO USE ONLY)
(b) Is the property to be served contiguous to the agency's boundary? YES NO. If yes, please provide explanation on why annexation to the agency is not being contemplated.
________________________________________________________________ ________________________________________________________________ ________________________________________________________________
5. Is the service agreement/contract outside the Agency’s sphere of influence in response to a threat to the public health and safety of the existing residents as defined by Government Code Section 56133(c)?
YES NO. If yes, please provide documentation regarding the circumstance (i.e. letter from Environmental Health Services or the Regional Water Quality Control Board). ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
6. (a) What is the existing use of the property?
________________________________________________________________ ________________________________________________________________ (b) Is a change in use proposed for the property ?
YES NO. If yes, please
provide a description of the land use change.
________________________________________________________________ ________________________________________________________________
7. If the service agreement/contract is for development purposes, please provide a complete description of the project to be served and its approval status. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Extension of Service by Contract ____________________
Application Form (FOR LAFCO USE ONLY)
8. Are there any land use entitlements/permits involved in the agreement/contract? YES NO. If yes, please provide documentation for this entitlement including the conditions of approval and environmental assessment that are being processed together with the project. Please check and attach copies of those documents that apply:
Tentative Tract Map / Parcel Map
Permit (Conditional Use Permit, General Plan Amendment, etc.) Conditions of Approval
Negative Declaration (Initial Study)
Notice of Determination (NOD)/Notice of Exemption (NOE) Department of Fish and Game (DFG) Receipt
Others (please identify below)
________________________________________________________________ ________________________________________________________________
9. Has the agency proposing to extend service conducted any CEQA review for this contract? YES NO. If yes, please provide a copy of the agency’s environmental assessment including a copy of the filed NOD/NOE and a copy of the DFG Receipt.
10. Plan for Service:
(a) Please provide a detailed description of how services are to be extended to the property. The response should include, but not be limited to, a description of:
1) capacity of existing infrastructure, 2) type of infrastructure to be extended or added to serve the area, 3) location of existing infrastructure in relation to the area to be served, 4) distance of infrastructure to be extended to serve the area, and 5) other permits required to move forward with the service extension. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Extension of Service by Contract ____________________
Application Form (FOR LAFCO USE ONLY)
________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ (b) Please provide a detailed description of the overall cost to serve the property.
The response should include the costs to provide the service (i.e. fees, connection charges, etc.) and also the costs of all improvements necessary to serve the area (i.e. material/equipment costs, construction/installation costs, etc.).
Description of Fees/Charges Cost Total
Total Costs
(c) Please identify any unique costs related to the service agreement such as premium outside City/District rates or additional 3rd-party user fees and charges (i.e. fees/charges attributable to other agencies).
________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Extension of Service by Contract ____________________
Application Form (FOR LAFCO USE ONLY)
(d) If financing is to occur, please provide any special financial arrangement between the agency and the property owner, including a discussion of any later repayment or reimbursement (If available, a copy of the agreement for repayment/reimbursement is to be provided).
________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 11 Does the City/District have any policies related to extending service(s) outside its boundary? YES NO. If yes, has a copy been provided to LAFCO? YES NO. If not, please include a copy of the policy or policies (i.e. resolution, municipal code section, etc.) as part of the application. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________
CCEERRTTIIFFIICCAATTIIOONN
As a part of this application, the City/Town of _________________, or the ______________________ District/Agency agree to defend, indemnify, hold harmless, promptly reimburse San Bernardino LAFCO for all reasonable expenses and attorney fees, and release San Bernardino LAFCO, its agents, officers, attorneys, and employees from any claim, action, proceeding brought against any of them, the purpose of which is to attack, set aside, void, or annul the approval of this application or adoption of the environmental document which accompanies it.
This indemnification obligation shall include, but not be limited to, damages, penalties, fines and other costs imposed upon or incurred by San Bernardino LAFCO should San Bernardino LAFCO be named as a party in any litigation or administrative proceeding in connection with this application.
The agency signing this application will be considered the proponent for the proposed action(s) and will receive all related notices and other communications. I understand that if this application is approved, the Commission will impose a condition requiring the applicant to indemnify, hold harmless and reimburse the Commission for all legal actions that might be initiated as a result of that approval.
Extension of Service by Contract ____________________
Application Form (FOR LAFCO USE ONLY)
I hereby certify that the statements furnished above and in the attached exhibits present the data and information required for this evaluation of service extension to the best of my ability, and that the facts, statement and information presented herein are true and correct to the best of my knowledge and belief.
SIGNED ________________________________
NAME: _____________________________
POSITION TITLE: _____________________________
DATE: _____________________________
REQUIRED EXHIBITS TO THIS APPLICATION:
1. Copy of the agreement/contract.
2. Map(s) showing the property to be served, existing agency boundary, the location of the existing infrastructure, and the proposed location of the infrastructure to be extended.
3. Certified Plan for Service (if submitted as a separate document) including financing arrangements for service.
Please forward the completed form and related information to:
Local Agency Formation Commission for San Bernardino County 1170 W. Third Street, Unit 150,
San Bernardino, CA 92415-0490
PHONE: (909) 388-0480 ● FAX: (909) 388-0481
Rev: krm – 8/19/2015
Jesus Plasencia
Assistant City Engineer