OOUUTT OOFF AAGGEENNCCYY SSEERRVVIICCEE AAGGRREEEEMMEENNTT Please complete the application in its entirety. All questions within the sections pertinent to the proposal must be answered.
APPLICANT (must be the public agency that is to provide service) Agency Name ___________________________________________ Contact Person/Title ___________________________________________ Mailing Address ___________________________________________ ___________________________________________
Phone Number ___________________________________________ E-mail Address ___________________________________________ SECTION 1: PARCEL AND PROPERTY OWNER INFORMATION
1. Parcel and property owner information.
Provide the following information for each parcel to receive service. Attach additional sheets if necessary.
Assessor’s Parcel Number(s) ____________________________________________________________ Site address, if applicable ________________ ____________________________________________ Name of Property Owner(s) ____________________________________________________________ Contact Person ________________________ ____________________________________ Contact Person Mailing Address ________________ ____________________________________________ Contact Person Phone Number ________________ ____________________________________________ Contact Person E-mail Address ______________ ______________________________________________ SECTION 2: PROPOSAL INFORMATION
2. Is the proposed serv ice new or extended?
New
Extended (an increase in the size or level of service)
3. What type of service is proposed to be provided? (check all that apply ) Water
Sewer
Other (explain):________________________________________________________________________ For LAFCo Use Only
File# ____________________
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VENTURA LOCAL AGENCY FORMATION COMMISSION
801 S. VICTORIA AVENUE,S UITE 301 z
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VENTURA,C A9 3 0 0 3
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TEL (805) 654-2576 z
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FAX (805) 477-7101
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WWW.VENTURA.LAFCO.CA.GOV
City of Thousand Oaks
Nader Heydari
2100 Thousand Oaks Blvd
Thousand Oaks, CA 91362
(805)449-2392
[email protected]
673-0-190-340
Hemlock Ln
Reza Azad
Reza Azad
99 Talisman Unit #333, Irvine, CA 92620
(949) 234-7392
[email protected]
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LAFCo Application for an Out of Agency Service Agreement
4. Agency’s ability to provide the proposed service(s).
A. Does the agency proposing to provide service(s) have the necessary contractual and design capacity to provide the service(s)?
Yes
No
B. Describe how the new service(s) is(are) proposed to be provided:
_____________________________________________________________________________________ C. What is the distance of the existing infrastructure to the site? _____________________________________________________________________________________ D. How will the improvements be financed?
_____________________________________________________________________________________
5. Services currently provided to the site.
A. Does the site to be served currently receive water?
Yes (by a private on-site water well).
Yes (by a public or private provider). Provider: ____________________________________________ No
B. Is sewage disposal currently provided to the site?
Yes (by means of a private disposal system (septic system)) Yes (by a public or private provider). Provider: ____________________________________________ No
6. If a water well or septic system exists on site, would it be abandoned upon approval of the requested OASA?
Water well: Yes No N/A (no well exists)
Septic system: Yes No N/A (no septic system exists) Wt͗ϰϮϬͲϴϵͰũƚͰĞƚŵͰĞǀͰŽƵŶĐŝůͰϮϬϮϰͰϬϮϮϳϮϰͰK^tĂƚĞƌtt^ĞƌǀŝĐĞ,ĞŵůŽĐŬ>ĂŶĞƚƚϯ͘ƉĚĨ Existing water (Dwg 20079 Sheet 7A) in street. Existing wastewater (Dwg 10609 Sheet 26) in street Water and Wastewater mains front parcel
By the owner paid in advance by the water/wastewater permit W-WW-2022-14000 ■
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LAFCo Application for an Out of Agency Service Agreement
SECTION 3: LAND USE
7. Land Use.
A. Describe the current la nd use of the property:
_____________________________________________________________________________________ B. Are there any proposed or approved (but not yet built) development projects on the property to be served?
No
Yes. Describe the proposed projects or the approved permits/land use entitlements, and specify permit/entitlement numbers and approval dates: ____________________________________________ _____________________________________________________________________________________ Permit/Entitlement and Permit Number: _______________________ Approval date: _______________ Permit/Entitlement and Permit Number: _______________________ Approval date: _______________
8. Do any public easements/oil well operations/cellular site leases, etc. currently exist on the site to be served?
Yes. Describe: _________________________________________________________________________ No
SECTION 4: CALIFORNIA ENVIRONMENTAL QUALITY ACT (CEQA) ANALYSIS
9. LAFCo’s action regarding this application is subject to the requirements of CEQA. Has the agency proposing to provide service, or any other agency, conducted CEQA review for any projects to be served as a result of this application?
No
Yes.
A. Identify the CEQA lead agency for the project: ________________________________________________ B. What type of CEQA document was prepared for the project? Notice of Exemption (CEQA Guidelines § __________________ Class Title :______________________) Negative Declaration
Mitigated Negative Declaration
Environmental Impact Report
If an EIR was prepared, were Statements of Overriding Considerations adopted? Yes – For which specific impacts? __________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ No
C. Please provide two copies of the environmental do cumentation, including the Notice of Exemption or Notice of Determination, and proof of payment of applicable California Department of Fish and Wildlife fees.
Wt͗ϰϮϬͲϴϵͰũƚͰĞƚŵͰĞǀͰŽƵŶĐŝůͰϮϬϮϰͰϬϮϮϳϮϰͰK^tĂƚĞƌtt^ĞƌǀŝĐĞ,ĞŵůŽĐŬ>ĂŶĞƚƚϯ͘ƉĚĨ The parcel is presently vacant
The owner/developer to submit plans for a
single family residence to County
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LAFCo Application for an Out of Agency Service Agreement
SECTION 5: GOVERNMENT CODE § 56133 STANDARDS
10. Is any portion of the area to be served contiguous (as defined in Government Code § 56031) to the boundary of the agency that is proposing to provide service(s)? Yes
No
11. Is the area to be served within the current sphere of influence of the agency that is proposing to provide service(s)?
Yes (respond to Question No. 12 and skip Question No. 13) No (skip Question No. 12 and respond to Question No. 13)
12. If the response to Question No. 11 is YES, does the agency proposing to provide service(s) have a projected timeframe within which it anticipates filing an application for annexation of territory that would include the area to be served?
Yes. Specify anticipated application filing date: _____________________________________________ No
13. If the response to Question No. 11 is NO, is the reason for the service to respond to an existing or impending threat to public health or safety?
Yes. Provide documentation confirming a public health and/or safety threat.
No. Identify all other alternative service providers that have jurisdiction over the area proposed to be served, including water corporations as defined in Public Utilities Code § 241 and sewer system corporations defined in Public Utilities Code § 230.6.
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
14. Are there any other service contracts/agreements currently in effect to serve the site? Yes. Describe the service: _______________________________________________________________ No
15. Are there any other service contracts/agreements currently in effect to serve any parcels immediately adjoining the site proposed for service?
Yes. Specify the Assessor’s Parcel Number(s): _______________________________________________ No
16. Have all property owners signed an agreement, agreeing to allow annexation of the site to the appropriate agency at such time as requested by the agency?
Yes
No
Wt͗ϰϮϬͲϴϵͰũƚͰĞƚŵͰĞǀͰŽƵŶĐŝůͰϮϬϮϰͰϬϮϮϳϮϰͰK^tĂƚĞƌtt^ĞƌǀŝĐĞ,ĞŵůŽĐŬ>ĂŶĞƚƚϯ͘ƉĚĨ ■
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LAFCo Application for an Out of Agency Service Agreement
CERTIFICATION
I certify under penalty of perjury, under the laws of the State of California, that the information contained in this application is true and correct. I acknowledge and agree that the Ventura Local Agency Formation Commission is relying on the accuracy of the information provided and my representations in order to process this application proposal.
I further certify that I am authorized by _________________________________________________ to sign this application on the agency’s behalf.
Date: _______________________________________
Signature: _______________________________________
Name: _______________________________________
Title: _______________________________________
Agency Name
Wt͗ϰϮϬͲϴϵͰũƚͰĞƚŵͰĞǀͰŽƵŶĐŝůͰϮϬϮϰͰϬϮϮϳϮϰͰK^tĂƚĞƌtt^ĞƌǀŝĐĞ,ĞŵůŽĐŬ>ĂŶĞƚƚϯ͘ƉĚĨ City of Thousand Oaks
Nader Heydari
Deputy Public Works Director/City Engineer
LAFCo Application for an Out of Agency Service Agreement
VVEENNTTUURRAA LLOOCCAALL AAGGEENNCCYY FFOORRMMAATTIIOONN CCOOMMMMIISSSSIIOONN CCOOUUNNTTYY GGOOVVEERRNNMMEENNTT CCEENNTTEERR z HHAALLLL OOFF AADDMMIINNIISSTTRRAATTIIOONN 880000 SS.. VVIICCTTOORRIIAA AAVVEENNUUEE z VVEENNTTUURRAA,, CCAA 9933000099--11885500 TTEELL ((880055)) 665544--22557766 z FFAAXX ((880055)) 447777--77110011 HHTTTTPP::////WWWWWW..VVEENNTTUURRAA..LLAAFFCCOO..CCAA..GGOOVV
INDEMNITY AGREEMENT
As part of this application, the applicant agrees to defend, indemnify, hold harmless and release the Ventura Local Agency Formation Commission (LAFCo), its officers, employees, attorneys, or agents from any claim, action or proceeding brought against an y of them, the purpose of which is to attack, set aside, void, or annul, in whole or in part, LAFCo’ s action on the proposal or on the environmental documents submitted to support it. This indemnific ation obligation shall include, but not be limited to, damages, costs, expenses, attorney fees, and expert witness fees that may be asserted by any person or entity, including the applicant, arising out of or in connection with the application.
LAFCo Case Name and No. ____________________________________________________ (LAFCO USE ONLY) Date: ______________________________________________
Applicant or Applicant’s Representative:
(Proof of authority to sign must be provided)
Signature: _______________________________________
Name: _______________________________________
Agency: _______________________________________
Title: _______________________________________
Address: _______________________________________
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Wt͗ϰϮϬͲϴϵͰũƚͰĞƚŵͰĞǀͰŽƵŶĐŝůͰϮϬϮϰͰϬϮϮϳϮϰͰK^tĂƚĞƌtt^ĞƌǀŝĐĞ,ĞŵůŽĐŬ>ĂŶĞƚƚϯ͘ƉĚĨ Andrew P Powers
City of Thousand Oaks
City Manager
2100 Thousand Oaks Blvd, CA 91362
LAFCo Application for an Out of Agency Service Agreement
VVEENNTTUURRAA LLOOCCAALL AAGGEENNCCYY FFOORRMMAATTIIOONN CCOOMMMMIISSSSIIOONN CCOOUUNNTTYY GGOOVVEERRNNMMEENNTT CCEENNTTEERR z HHAALLLL OOFF AADDMMIINNIISSTTRRAATTIIOONN 880000 SS.. VVIICCTTOORRIIAA AAVVEENNUUEE z VVEENNTTUURRAA,, CCAA 9933000099--11885500 TTEELL ((880055)) 665544--22557766 z FFAAXX ((880055)) 447777--77110011 HHTTTTPP::////WWWWWW..VVEENNTTUURRAA..LLAAFFCCOO..CCAA..GGOOVV AGREEMENT FOR PAYMENT OF LAFCo FEES
Applicant: _________________________________________________________________________________ LAFCo Case Name and No. ____________________________________________________ (LAFCO USE ONLY) For an Administrative Action (p ursuant to the current Ventura LAFCo Fee Schedule), the Applicant understands and agrees as follows:
1. LAFCo has established a fee schedule pursuant to Government Code § 56383 to recover a portion of the estimated reasonable costs of LAFCo proc eedings. Applicant has submitted a request for action to LAFCo that requires a flat fee in acco rdance with the fee schedule. Applicant hereby pays the flat fee of $450 to reimburse LAFCo for costs associated with the request.
For a Commission Action (pursuant to the current Ventura LA FCo Fee Schedule), the Applicant understands and agrees as follows:
1. LAFCo has established a fee schedule pursuant to Government Code § 56383 to recover a portion of the estimated reasonable costs of LAFCo proc eedings. Applicant has submitted a request for action to LAFCo that requires a flat fee and an in itial deposit of funds, in accordance with the fee schedule. Applicant hereby pays the flat fee of $1,850 and the initial deposit fee of $1,800 to reimburse LAFCo for costs associated with the request.
2. LAFCo’s costs of processing the request, consisting of LAFCo staff time at hourly rates based on the most recent LAFCo fee schedule, and all direct LAFCo costs associated with Applicant’s request, will be charged to Applicant and deducted from the initial deposit fee. LAFCo’s costs include but are not limited to: (a) Staff time spent reviewing ap plication materials, responding by phone or correspondence to all inquiries relating to the request, preparing reports, attendance and participation at meetings, and making filings ne cessary to complete proceedings, and; (b) Direct costs for public notices, legal counsel, County, st ate and federal agency review and information, and consultants hired by LAFCo to assist in the review and processing of the request.
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Wt͗ϰϮϬͲϴϵͰũƚͰĞƚŵͰĞǀͰŽƵŶĐŝůͰϮϬϮϰͰϬϮϮϳϮϰͰK^tĂƚĞƌtt^ĞƌǀŝĐĞ,ĞŵůŽĐŬ>ĂŶĞƚƚϯ͘ƉĚĨ Reza Azad
LAFCo Application for an Out of Agency Service Agreement
3. If the LAFCo Executive Officer determines the init ial deposit fee is insufficient to reimburse all of LAFCo’s costs incurred and to be incurred to complete the requested action, LAFCo will bill Applicant for, and Applicant must pay, an additional deposit equal to the additional fee estimated by the Executive Officer as necessary to fully reimburse LAFCo.
4. After all requested actions are complete the LAFCo Executive Officer will compute the actual final costs and will refund any unused portion of the de posit, or will bill Applicant for any unreimbursed costs. Any refunds will be solely for the unused portion of the deposit and will not include any interest.
5. If Applicant fails to pay in fu ll any sums billed by LAFCo within 15 days of the billing, the LAFCo Executive Officer may stop processing Applicant’ s request and/or set the request for hearing by LAFCo with a recommendation for denial due to fa ilure to pay fees. The Executive Officer shall not be required to record a certificate of completion or otherwise complete any requested action until and unless all fees are paid in full.
6. Applicant may make a written request to LAFCo for an accounting of billed sums, and LAFCo will respond within a reasonable period. Applicant’s ob ligations to pay the required fees shall not be delayed or deferred by such a request.
7. The undersigned is (check one):
The individual applicant or petitioner who agrees to be bound by the terms of this agreement and to pay the sums due LAFCo.
The authorized representative of the Applican t who is empowered to execute this agreement and who agrees the Applicant shall be bound by its terms and shall pay the sums due LAFCo.
The property owner or real party in interest for an application or petition filed or to be filed with LAFCo by a City or Special District. I agree to be bound by the terms of this agreement as they are applicable to A pplicant and to pay to LAFCo all sums due from Applicant. I agree that notice to Applicant of any obligation arising hereunder shall be construed to be notice to me.
Date: _________ _____________________________
Signature: _______________________________________
Name: _______________________________________
Address: _______________________________________
Telephone: _______________________________________
Wt͗ϰϮϬͲϴϵͰũƚͰĞƚŵͰĞǀͰŽƵŶĐŝůͰϮϬϮϰͰϬϮϮϳϮϰͰK^tĂƚĞƌtt^ĞƌǀŝĐĞ,ĞŵůŽĐŬ>ĂŶĞƚƚϯ͘ƉĚĨ Nader Heydari
2100 E Thousand Oaks Blvd Thousand Oaks, CA 91362
(805)449-2392
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