County of Santa Clara
Office of the County Clerk-Recorder
Business Division
County Government Center
70 West Hedding Street, E. Wing, 1
st
Floor
San Jose, California 95110 (408) 299-5688
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
1. ENVIRONMENTAL IMPACT REPORT (PUBLIC RESOURCES CODE §21152) $ $_______________
2. NEGATIVE DECLARATION (PUBLIC RESOURCES CODE §21080(C) $ $_______________
3
. APPLICATION FEE WATER DIVERSION (STATE WATER RESOURCES CONTROL BOARD ONLY) $ $_______________
4
. PROJECTS SUBJECT TO CERTIFIED REGULATORY PROGRAMS $ $_______________
5
. COUNTY ADMINISTRATIVE FEE (REQUIRED FOR a-1 THROUGH a-4 ABOVE) $ $_______________
Fish & Game Code §711.4(e)
b
. PROJECTS THAT ARE EXEMPT FROM DFG FEES
1. NOTICE OF EXEMPTION ($50.00 COUNTY ADMINISTRATIVE FEE REQUIRED) $ $_______________
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 $ $_______________
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): $_______________
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 TWO (2) COPIES. IF THERE ARE ATTACHMENTS, PLEASE
PROVIDE THREE (3) SETS OF ATTACHMENTS FOR SUBMISSION. (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 01-01-2020)
NOTE:
Before printing, be sure to Update the Total Value by
clicking in the RED BOX at the bottom of this form.
